This nine-question dental intake form opens by collecting a patient's full legal name and date of birth to create an accurate record, then asks for the primary reason for today's visit so the dental team can prepare before the appointment. The last dental visit question accepts an approximate date, Never, or Unknown, while the following two open-ended questions on current medications and known allergies flag anything that could affect treatment safety. Patients then select relevant medical conditions — such as diabetes, heart disease, or a bleeding disorder — and prior dental treatments, from fillings to implants. An optional final text question lets patients describe treatments not listed in the choices. After submitting, patients see a confirmation screen thanking them for their time and explaining how the information supports their upcoming care.
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Relies on the "What is the primary reason for your dental visit today?" question and the two multiple-choice questions to prepare the team for each patient's specific needs before they arrive.
Depends heavily on the "Are you currently taking any medications (prescription or over-the-counter)? Please list them." question and the medical conditions question to assess surgical risk upfront.
Uses the "Have you had any significant dental treatments in the past? Select all that apply." question — particularly the fillings, crowns/bridges, and implants options — to understand the structural history of a new patient's teeth.
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