Dental Patient Intake Form
A dental patient intake form covers what has to be known before an instrument goes anywhere near a patient: medical history, medication, allergies, and how they feel about being in the chair.
For dental practices, orthodontists and hygienists.
Anxiety belongs on the medical history
Dental anxiety is clinically relevant. It changes appointment length, technique, whether sedation is discussed, and whether a patient turns up at all - and almost nobody volunteers it at a front desk.
Asked as an ordinary scale question on a form, people answer honestly. Read it before the appointment and a nervous patient gets a longer first visit, an explanation before each step, and a much better chance of coming back. It's the most under-used question in dentistry.
Why ask it all up front
Half-finished information is worse than none: it looks like you can begin, and then you can't. A patient who fills in one page has told you enough to quote, schedule and prepare - without a single back-and-forth.
It also sets the tone. A form that asks precisely, and only once, reads as a business that has done this before. That impression is doing real work while your competitor is still emailing "quick question".
Medical history before the chair, not in it
Medical history, medication and anxiety level asked at reception get rushed and under-reported. Sent with the appointment confirmation, they arrive complete, read properly, and give you the ten minutes back.
It also flags the appointments that need different planning - a sedation conversation, a longer slot, a change of technique - before the day rather than at the door.
It works on a phone, on a bad signal
People fill these in from a car park, a waiting room, a sofa at 11pm. This form is one small page that opens the instant they tap the link and submits without needing anything clever in their browser - so an answer sent on two bars still reaches you.
One minute to make it your own
Every label, option and placeholder on this template is editable, and you can add whatever this template doesn't ask. Save to publish, share the link, and export the responses whenever you need them in a spreadsheet.
What this template asks
- Full name
- Date of birth
- Email address
- Phone number
- Home address
- Doctor's name and practice
- Do any of these apply to you?
- Medication you take
- Allergies
- Are you pregnant or breastfeeding?
- Do you smoke or vape?
- When did you last see a dentist?
- Any of these?
- How do you feel about dental treatment?
- Has anything put you off in the past?
- The information above is accurate and I'll tell you if it changes
More Dental forms
Questions
Is a web form appropriate for medical history?
Responses are encrypted in transit and stored in your account, never shared. You remain the controller: ask what's clinically necessary, tell patients what you keep, and confirm your obligations under HIPAA, UK GDPR or your local equivalent.
How often should we re-ask?
At every course of treatment, and at least annually. Sending the same link means the responses build a dated history rather than overwriting the last one.
Can I add or remove questions?
Yes - every question here is a starting point. Add your own, delete what doesn't apply, reorder by dragging, and make anything required or optional. Saving publishes the change immediately.
Where do the answers go?
Into your dashboard, where you can read, filter and export them as a spreadsheet. You can also have every response emailed to you the moment it arrives, or as a daily or weekly digest.
Do I need a website?
No. Every form gets its own link you can paste into an email signature, a text message, a QR code or a social profile. If you do have a site, you can link to it from anywhere on it.
Can this hold patient medical information?
Responses are stored in your account, never shared, and served over encrypted connections - but you are the data controller. Ask only what you need clinically, tell patients what you keep, and check your local rules (HIPAA, UK GDPR and similar) before using a web form for health data.
Publish your dental patient intake form today
Start from this template and change anything you like. Free to begin.