Dental Patient Intake Form
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Address
City
State
Zip
Phone
Email
Emergency Contact Name
Emergency Contact Phone
Relationship
Primary Physician
Medical History (Choose all that apply)
Diabetes
Hypertension
Heart Disease
Asthma
None
Known Allergies
Current Medications
Reason for Dental Visit
Additional Notes