Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Dental Patient Intake Form
Dental Patient Intake Form Please complete all sections of this form before your appointment. Your responses help us provide safe, personalized dental care.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Address *
Emergency Contact Name *
Emergency Contact Phone *
Dental Insurance & History Please provide your insurance details and dental history below.
Dental Insurance Provider
Policy Number
Date of Last Dental Visit
____ / ____ / ________
Reason for Today's Visit *
Current Dental Concerns
- Tooth Pain
- Sensitivity
- Bleeding Gums
- Cosmetic Concerns
- TMJ
- Grinding or Clenching
- Bad Breath
- None
Previous Dental Treatments
- Braces
- Root Canal
- Extractions
- Implants
- Dentures
- Crown or Bridge
- None
Do You Floss Daily? *
- Yes
- No
Brushing Frequency *
- Once daily
- Twice daily
- More than twice
Fear of Dental Procedures *
- None
- Mild
- Moderate
- Severe
Allergies
Current Medications
Medical Conditions
- Diabetes
- Heart Disease
- High Blood Pressure
- Bleeding Disorder
- Hepatitis
- HIV
- Pregnancy
- None
Dental Patient Intake Form template from formisoft.com. formisoft.com/intake-templates/dental-intake