Why does my dentist need my medical history?

Your medical history directly affects dental treatment decisions. Conditions like heart disease, diabetes, osteoporosis, and blood thinners all affect how your dentist plans procedures, which anaesthetics are safe, and whether antibiotics are needed before treatment.

Can I complete my dental intake form online before my appointment?

Yes - many dental practices now accept pre-completed intake forms. Our free online form can be completed at home, exported as PDF, and brought to your appointment or emailed to your dental practice in advance.

Free Dental Patient Intake Form 2026 - Printable & PDF Export

Q: What information is on a dental intake form?

A standard dental intake form covers: personal details, emergency contact, current medications and supplements, known allergies, medical conditions (especially heart disease, diabetes, blood thinners), previous dental treatments, dental concerns, insurance information, and consent for treatment.

Patient Intake Form

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Phone Number

Email Address

Home Address

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone

Insurance Information

Insurance Company

Plan / Group Name

Member ID

Group Number

Primary Policy Holder (if not self)

Want to estimate your out-of-pocket costs before your appointment? Use our Dental Insurance Calculator.

Dental Concerns

Chief Complaint / Reason for Visit

Do you have any of the following? (Select all that apply)

Toothache or tooth pain

Tooth sensitivity (hot/cold/sweet)

Bleeding gums when brushing/flossing

Facial swelling or lumps

Jaw pain or clicking/popping

Persistent bad breath

Dry mouth

Loose or shifting teeth

Date of Last Dental Visit

Dental Anxiety Level (1 = none, 10 = severe)

How anxious are you about dental treatment? 5

For a full anxiety assessment, use our Dental Anxiety Assessment tool.

Medical History

Your medical history directly affects dental treatment. Please answer accurately - this information is kept confidential.

Heart disease or heart conditions

High blood pressure (hypertension)

Diabetes (Type 1 or Type 2)

Taking blood thinners (warfarin, aspirin, etc.)

Osteoporosis / bisphosphonate medication

Asthma or respiratory conditions

Currently pregnant or breastfeeding

HIV / AIDS

Cancer or cancer treatment (chemo/radiation)

Kidney disease or dialysis

Liver disease (hepatitis, cirrhosis)

Latex allergy

Other medical conditions or relevant information

Allergies

Penicillin or antibiotics

Aspirin or NSAIDs (ibuprofen, naproxen)

Codeine or opioid pain medications

Local anaesthetic (novocaine, lidocaine)

Latex / rubber

Other allergies (food, environment, medications)

Current Medications & Supplements

Include all prescription medications, over-the-counter drugs, vitamins, and herbal supplements. Many affect dental treatment and local anaesthesia.

Medication / Supplement Name

Dose

No medications added yet. Click "+ Add" to add a medication or supplement.

Consent & Signature

I certify that the information I have provided on this form is correct and complete to the best of my knowledge. I understand that this information is needed for my dental care and may affect treatment decisions. I consent to the dental examination and necessary treatment recommended by my dental provider.

I authorise my dental provider to release information necessary for insurance claim processing. I understand that I am financially responsible for all charges not covered by my insurance plan.

I have read and agree to the above consent statement *

Required to complete the form

Patient Name (Signature)

Date

✅

Form Complete!

Your intake form is ready. Export as PDF or print to bring to your appointment.

Why Complete Your Dental Intake Form in Advance?

Completing your dental patient intake form before your appointment has clear benefits for both you and your dental team. It reduces waiting room time, ensures your dentist has a complete and accurate picture of your health before your appointment, and gives you time to gather accurate information about your medications and medical history without feeling rushed.

Pair this form with our Dental Appointment Checklist to ensure you bring everything you need. If you want to estimate your treatment costs before you arrive, our Treatment Cost Estimator lets you calculate your out-of-pocket costs for any procedure based on your insurance details.

Why Your Medical History Matters for Dental Treatment

Many medical conditions and medications directly affect dental treatment decisions. Here's why each section matters:

Heart disease: Some cardiac patients require antibiotic pre-medication before dental procedures to prevent infective endocarditis
Blood thinners: Warfarin, aspirin, and newer anticoagulants affect bleeding during extractions and surgical procedures
Diabetes: Poorly controlled diabetes impairs healing and increases infection risk - your dentist may adjust treatment timing
Bisphosphonates (osteoporosis medication): These drugs increase the risk of osteonecrosis of the jaw after extractions or implant placement
Pregnancy: Certain X-rays, medications, and treatment timings are modified for pregnant patients
Allergies to local anaesthetic: True allergy is rare but critical - your dentist must know so alternative agents can be used

Frequently Asked Questions

What information is on a dental intake form?

A standard dental intake form covers: personal details (name, DOB, contact info), emergency contact, current medications and supplements, known allergies, medical conditions (especially heart disease, diabetes, blood thinners, osteoporosis), previous dental treatments, current dental concerns, insurance information, and signed consent for treatment. Our form covers all of these sections.

Is my information stored when I complete this form?

No. All form data exists only in your browser session and is never transmitted to any server. When you close or refresh the page, the data is cleared. We recommend exporting as PDF or printing immediately after completion. Your privacy is fully protected - there are no accounts, no logins, and no data collection.

Can I send this form to my dentist by email?

Yes - export the form as PDF and attach it to an email to your dental practice. Many practices now accept patient intake forms electronically in advance of appointments. Contact your dental office to confirm their preferred method of receiving pre-completed forms.

Do I need to update my intake form at every visit?

Most dental practices ask you to review and update your medical history annually, or whenever there is a significant change - new medical condition, new medications, surgery, or change in health status. Always tell your dental team about any new medications started since your last visit, even if they seem unrelated to your teeth.

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💡 Preparation Tip

Complete this form while reviewing your medication bottles - you'll have the exact name, dose, and frequency in front of you, reducing errors. Also use our Appointment Checklist to prepare everything else.