Pediatric Dental Intake Form
A pediatric dental intake form asks the parent two kinds of question: the clinical history, and how this particular child copes. The second is what makes a first visit go well.
For dental practices, orthodontists and hygienists.
Ask what has worked before, and what hasn't
A child who had a difficult extraction at four arrives at six already frightened, and nobody in the room knows unless the parent is asked. Equally, a parent usually knows exactly what helps - counting, a mirror, being told each step, a favourite character.
So this template asks about previous experiences and about what calms this child specifically. It also asks about habits - thumb sucking, bottles at night, dummy use - which are clinically relevant and rarely mentioned unprompted.
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
- Child's full name
- Date of birth
- Parent or guardian name
- Email address
- Phone number
- Doctor's practice
- Does your child have any of these?
- Medication your child takes
- Allergies
- Has your child seen a dentist before?
- Any of these?
- How often are teeth brushed?
- How often are sugary drinks or snacks had?
- Anything you've noticed?
- How does your child feel about coming?
- What helps your child cope?
- Anything that went badly before?
- I am the parent or legal guardian and consent to my child being examined
More Dental forms
Questions
Who should fill this in?
A parent or legal guardian, and the form should say so - it asks for a confirmation at the end. Keep the language aimed at the parent rather than the child.
Can we ask about diet?
Yes, and it's worth it: frequency of sugary drinks and snacks matters more than quantity. Keep it to two questions so it reads as clinical rather than judgemental.
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 pediatric dental intake form today
Start from this template and change anything you like. Free to begin.