Dental Preventive Exam Intake Form

First Name

Last Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Preferred Contact Method

Other

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Requested Appointment

Preferred Dentist or Hygienist

Visit Type / Reason for Visit

Scheduling Notes / Availability Constraints

Date of Last Dental Visit

Date

Current Dental Concerns or Symptoms

History of Dental Anxiety

Prior Dental Treatments or Procedures

Recent Dental X-rays

Medical conditions that apply

Current medications

Allergies or sensitivities

Pregnancy status

Tobacco or vape use

Conditions, concerns, or treatment considerations that may affect dental care

Dental Insurance Provider Name

Policyholder Name (if different)

First NameMiddle NameLast Name

Billing or Record Preparation Notes

Acknowledgment

Additional Comments, Concerns, or Special Instructions