Pre-Appointment Intake Sheet
Fill in the medical and dental history a new practice will ask for, then print it, instead of doing it on a clipboard in the waiting room.
Fill this in, print it, and hand it over at reception. Everything stays in this browser tab. Nothing is saved, uploaded, or sent to us, which also means it is gone when you close the page, so print before you leave.
New patient information
You
In an emergency
Medical history
Diabetes, heart conditions, high blood pressure, autoimmune conditions, pregnancy. These change how dental treatment is planned.
Include blood thinners and bisphosphonates specifically, and anything that causes dry mouth.
Especially latex, penicillin, and any local anesthetic.
Dental history
Where it hurts, since when, what makes it worse, and whether it wakes you at night.
Braces or aligners, root canals, extractions, implants, crowns, gum treatment.
Gag reflex, needles, the sound, anesthetic not working, a past bad experience. Practices adapt when told and almost never notice when not.
Payment
Signature ______________________________ Date ______________
This is a generic sheet, not any particular practice’s official form, and it does not replace one. Most practices will still have you sign their own consent and privacy paperwork.
Other tools
This tool runs entirely in your browser. Nothing you type is sent to a server or stored. It is an estimate for planning only and is not dental advice.