Inclusivity Resources


Patient Intake Form Examples

Provided below are examples of medical and dental intake forms used by other organizations to collect pertinent patient information to ensure a positive and thorough care experience. Please use these for inspiration of how you can edit your own forms to accommodate the needs of your patients.

Fenway Health Intake Form

Strong Memorial Hospital Intake Form

Callen-Lorde Community Health Center


Non-Discrimination Policies

Creating and broadly communicating a patient non-discrimination policy that includes explicitly inclusive language allows patients and families to feel safe and welcomed at your office - it can even be the deciding factor for a patient when determining where to receive care. These policies can be added to your website, a patient bill of rights poster, or any publicly available signage accessible to your patients.


Non-Discrimination Policy Examples

"The mission of the American Academy of Pediatrics (AAP) is "to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults." In support of this mission, therefore, the AAP is opposed to discrimination in the care of any patient on the basis of race, ethnicity, ancestry, national origin, religion, gender, marital status, sexual orientation, gender identity or expression, age, veteran status, immigration status, or disability of the patient or patient's parent(s) or guardian(s)."
     ~Nondiscrimination in Pediatric Health Care


"The American Medical Association (AMA) supports the equal rights, privileges and freedom of all individuals and opposes discrimination based on sex, sexual orientation, gender identity, race, religion, disability, ethnic origin, national origin, or age."
    ~Policies on Lesbian, Gay, Bisexual, Transgender, & Queer (LGBTQ) issues

"The American Academy of Family Physicians (AAFP) opposes all discrimination in any form, including but not limited to, on the basis of actual or perceived race, color, religion, gender, sexual orientation, gender identity, ethnic affiliation, health, age, disability, economic status, body habitus or national origin."
   ~Discrimination, Patient

General Resources

Provided below are more resources to encourage proactive inclusivity and offer more sources for everyone's ongoing education.

"Avoiding Gender Identity Discrimination in Your Office" - ADA Article 

Professional Resources for Healthcare Professionals - Human Rights Campaign Foundation

Management of Muslim Dental Patient While Fasting - European Journal of General Dentistry

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