Dental Patient Intake Form

Asks about dental insurance provider, policy number, and date of last dental visit. Built for general dentistry and family dental practices.

Questions: 20
Pages: 2
Time: about 5 min

E-signature

Your practice

Page 1 of 2

Full Name

Date of Birth

Email Address

Phone Number

Address

Emergency Contact Name

Emergency Contact Phone

Live preview. Tap through it like a patient.

Who it is for

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

Formisoft for Dental Formisoft for Pediatrics

What's inside

Page 1

Full NameText · Required
Date of BirthDate · Required
Email AddressEmail · Required
Phone NumberPhone · Required
AddressLong Text · Required
Emergency Contact NameText · Required
Emergency Contact PhonePhone · Required

Page 2

Dental Insurance ProviderText
Policy NumberText
Date of Last Dental VisitDate
Reason for Today's VisitText · Required
Current Dental ConcernsCheckbox · 8 choices
Previous Dental TreatmentsCheckbox · 7 choices
Do You Floss Daily?Multiple Choice · 2 choices · Required
Brushing FrequencyMultiple Choice · 3 choices · Required
Fear of Dental ProceduresMultiple Choice · 4 choices · Required
AllergiesLong Text
Current MedicationsLong Text
Medical ConditionsCheckbox · 8 choices
Patient SignatureE-Signature · Required

From form to a ready patient

01
Make it yours
Reword, reorder, or add to the Dental Patient Intake Form, and add your logo.
02
Patients finish it at home
A secure link by text or email, filled out on their phone before the visit. No app.
03
Your team sees who is ready
Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 20 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Dental Patient Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

Use this template