Dental Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Address
City
State
Zip Code
Phone
Email
Emergency Contact
Name
Relationship
Phone
Insurance Information
Insurance Provider
Policy Number
Group Number
Medical History
Diabetes
Asthma
Hypertension
Heart Disease
Other
List any medications you are currently taking
List any allergies
Dental History
Sensitive Teeth
Bleeding Gums
Teeth Grinding
Jaw Pain
Recent Cavities
Last dental visit
Dental concerns or reasons for today's visit