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Dental Patient Intake
Please complete before your first appointment. It takes about five minutes.
Full name
*
(required)
Date of birth
*
(required)
Email address
*
(required)
Phone number
*
(required)
Home address
*
(required)
Doctor's name and practice
Medical history
Do any of these apply to you?
*
(required)
Heart condition
High blood pressure
Diabetes
Asthma
Epilepsy
Bleeding disorder
Rheumatic fever
Artificial joint or valve
Hepatitis
Cancer treatment
None of these
Medication you take
*
(required)
Allergies
*
(required)
Are you pregnant or breastfeeding?
Select…
No
Yes
Not applicable
Prefer not to say
Do you smoke or vape?
*
(required)
Select…
No
Occasionally
Daily
I used to
Dental history
When did you last see a dentist?
*
(required)
Select…
Within 6 months
6 - 12 months
1 - 3 years
Over 3 years
I can't remember
Any of these?
Bleeding gums
Sensitivity
Grinding or clenching
Jaw pain or clicking
Bad breath
Unhappy with appearance
Missing teeth
None of these
How do you feel about dental treatment?
0
1
2
3
4
5
6
7
8
9
10
Completely relaxed
Extremely anxious
Has anything put you off in the past?
The information above is accurate and I'll tell you if it changes
*
(required)
Leave this field empty
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