New Patient Intake Form Template

How to use this template

Copy the sections below in order. Two rules matter more than the specific wording.

First, put the easy identity questions first and the insurance questions second. Patients build momentum; a form that opens with 'group number' loses people at question one. Second, mark only genuinely blocking fields as required. A required field the patient cannot answer from where they are sitting does not produce the answer, it produces an abandoned form. Let them proceed and follow up on the gap.

If you are delivering this as a message-based conversation rather than a form, split it at the section boundaries. Five short exchanges complete far more often than one long one.

Section 1: Patient identity

Every field here should be answerable from memory, which is why this section goes first.

• Legal first and last name (required)
• Preferred name
• Date of birth (required)
• Home address, city, state, postcode
• Mobile phone number (required)
• Email address
• Preferred contact method: text, call, or email (required)
• Preferred language
• Emergency contact name and phone
• How did you hear about us?

Section 2: Insurance

Expect this section to be the one that stalls, and design for a second attempt rather than treating a gap as a failure. The subscriber questions should only appear when the patient indicates they are not the subscriber.

• Do you have dental insurance? (required)
• Insurance carrier
• Member ID
• Group number
• Are you the primary subscriber? (required if insured)
• If not: subscriber's full name, date of birth, and your relationship to them
• Do you have secondary dental coverage?

Section 3: Health history

These questions change clinical decisions, so a blank has to be treated as unknown rather than 'no'. Where a patient answers yes, ask the follow-up rather than accepting the yes.

• Are you currently taking any medications? If yes, please list them.
• Do you have any allergies, including to medications, latex, or anaesthetic? If yes, which?
• Are you taking any blood thinners or anticoagulants?
• Do you have any heart conditions, or have you had heart surgery or a valve replacement?
• Do you have diabetes? If yes, is it well controlled?
• Are you pregnant or nursing?
• Do you have any bleeding disorders?
• Have you had surgery or been hospitalised in the last twelve months?
• Do you use tobacco products?
• Is there anything else about your health we should know?

Section 4: Dental history and this visit

This section is short and often skipped by practices, which is a mistake; it is what lets the provider walk in with context rather than starting cold.

• When was your last dental visit?
• Where were you seen previously? (for records and radiographs)
• What brings you in today?
• Are you currently in any pain or discomfort?
• Do you have any anxiety about dental treatment?
• How often do you currently floss and brush?

Variation A: Pediatric

Replace Section 1 with the child's identity plus the responsible party's, because the person answering is not the patient. Insurance is almost always under a parent, so make the subscriber block the default rather than conditional.

• Child's legal name, preferred name, and date of birth
• Parent or guardian name, relationship, mobile, and email
• Who is financially responsible for this account?
• Is there a custody arrangement we should be aware of?
• Who else is authorised to bring the child to appointments?
• Birth history and any developmental concerns
• Thumb, finger, or pacifier habits
• Has the child had dental treatment before, and how did they respond?

Variation B: Periodontal

Add to Section 3 rather than replacing it. These questions inform periodontal risk assessment and the maintenance interval that follows.

• Have you been told you have gum disease or received deep cleaning treatment?
• Do your gums bleed when brushing or flossing?
• Have you had any teeth become loose or move position?
• Is there a family history of gum disease or early tooth loss?
• Do you grind or clench your teeth?
• For tobacco users: how much, and for how long?

Variation C: Short pre-visit confirmation

For returning patients, a full re-completion annually is the standard, but a short confirmation at every visit catches the changes that matter. Six questions is enough and takes under a minute in a text conversation.

• Has your address or phone number changed?
• Has your insurance changed since your last visit?
• Have you started any new medications?
• Have you had any new allergies or reactions?
• Have you had surgery or a hospital stay since we last saw you?
• Is there anything bothering you that you would like us to look at?

Frequently asked questions

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