Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Pediatric Dentistry Intake Form
Your information
Child's Information
Date of Birth
____ / ____ / ________
Parent/Guardian Information
Parent/Guardian Phone
Parent/Guardian Email
Child's Dental History
Dental Anxiety Level
- Not anxious
- A little anxious
- Moderately anxious
- Very anxious
Oral Habits Assessment
Additional details
Dietary & Bottle Habits
Fluoride Exposure History
Medical Conditions
Allergy Information
| Allergy | Reaction |
|---|---|
Special Needs & Accommodations
Prior Sedation History
Dental Insurance
Parent/Guardian Consent
Date
Pediatric Dentistry Intake Form template from formisoft.com. formisoft.com/intake-templates/pediatric-dentistry-intake