Dental Intake template

A dental intake form that asks what most medical intake forms don't: how the patient feels about being in the chair. Alongside visit reason, last-visit date, insurance, and dental history, a 1–10 comfort rating flags anxious patients before they arrive — so the practice can plan extra care instead of discovering mid-appointment.

Use this template Start free — no card

6 questions · Free plan: 500 responses/month · fully customizable

Interactive — fill it in like a respondent would.Open full width

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Your contact detailsContact info

02When was your last dental visit?Date

03What would you like us to look at?Checkboxes

04How comfortable do you feel about dental visits?Rating scale

05Dental insurance provider and member IDShort text

06Anything about your dental history we should know?Long text

When to use this template

A dental office sending intake with booking confirmations so hygienists review concerns before the patient sits down
A practice that sees many lapsed patients, where the last-visit date sets expectations for the first appointment's scope
A cosmetic-focused practice separating consultation requests from cleanings via the visit-reason checklist
An office that wants anesthetic reactions and past treatment history flagged in writing, not recalled in the chair

Tips to get more from it

The comfort rating's own helper text promises extra care for anxious patients — treat low scores as an operational flag, and consider noting them in your scheduling system
"What would you like us to look at" is a multi-select with Other enabled, so a patient can tick both a checkup and a chipped tooth in one visit request
The last-visit date field says an estimate is fine; keep that reassurance, since lapsed patients often abandon forms that demand precision they don't have
Insurance is optional by design — the helper text tells out-of-pocket patients to leave it blank

Questions people ask

Can patients complete dental intake forms from their phone?

Yes, Zunoform forms are responsive, and this one uses a conversational layout that shows one question at a time — comfortable to complete on a phone in a couple of minutes.

Is this dental intake template free?

Yes. Every field in it publishes on the free plan, which includes unlimited forms and 500 responses per month.

Can I add my own questions, like medication or medical history?

Yes — add fields in the editor, or borrow the branching pattern from Zunoform's Medical History template if you want yes/no questions that reveal detail fields only when needed.