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Intake

Dental Patient Intake Form

2 pages•13 fields•HIPAA-ready
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Patient Information
Date of Birth
Phone Number
Email Address
Dental History
Diabetes
Hypertension
Asthma
Heart Disease
Last Dental Visit
Previous Dental Work
Diabetes
Hypertension
Asthma
Heart Disease
Dental Anxiety Level
TMJ/Jaw Pain Symptoms
Diabetes
Hypertension
Asthma
Heart Disease
Oral Hygiene Habits
Select...
Medical Conditions Affecting Dental
Diabetes
Hypertension
Asthma
Heart Disease
Dental Insurance
Insurance carrier & policy
Consent to Treatment
I agree to the terms above
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The Dental Patient Intake Form covers everything a dental practice needs to know before treating a new patient. Beyond standard demographics and insurance, this template includes dental-specific sections: oral health history, previous dental procedures and restorations, TMJ/jaw pain screening, dental anxiety assessment using a validated scale, and oral hygiene habits.

The medical history section is tailored for dental relevance, focusing on conditions that affect dental treatment such as bleeding disorders, heart conditions requiring antibiotic prophylaxis, bisphosphonate use, and latex allergies. Current medications are captured with attention to drugs that cause dry mouth, gingival hyperplasia, or affect bleeding.

This template works for general dentistry, orthodontics, periodontics, oral surgery, and pediatric dental practices. The dental anxiety scale helps the clinical team prepare appropriate comfort measures for anxious patients, improving the overall patient experience and reducing cancellations.

What's included

  • Dental history and previous procedures
  • TMJ screening and dental anxiety assessment
  • Oral hygiene habits evaluation
  • Conditions checklist for dental-relevant medical history
  • Insurance info collection and verification
  • Consent agreement for dental treatment
  • Insurance information collection with carrier and policy details

Who uses this template

  • General dentistry and family dental practices
  • Orthodontic offices
  • Oral surgery and periodontics practices
  • Pediatric dental clinics

All form fields

13 fields across 2 pages. Customize any field after signing up.

Patient InformationText
Date of BirthDate
Phone NumberPhone
Email AddressEmail
Dental HistoryConditions
Last Dental VisitDate
Previous Dental WorkConditions
Dental Anxiety LevelMultiple Choice
TMJ/Jaw Pain SymptomsConditions
Oral Hygiene HabitsDropdown
Medical Conditions Affecting DentalConditions
Dental InsuranceInsurance Info
Consent to TreatmentConsent Agreement
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