Make a dental patient intake form for your practice's new patients
Build a new-patient intake form for your dental practice in a chat: contact details, reason for visit, anxiety level, last visit and insurance.
Contact us
We usually answer within a day.
This is a real form: answer it the way a visitor would. Nothing is saved.
Use this template Describe yours in chatOpen full screenMore to start from: all form, quiz and course templates. Nothing is published until you press Publish, and every answer lands in your account with charts and a CSV.
A new-patient form at a dental practice has to do several jobs at once: collect the basics for the file, learn why the person is coming in, and flag anxiety early so the team can plan the appointment. Paper forms get lost and typed answers often come back half-finished. The live sample above is a general contact form; the chat adapts it into a dental intake form for your practice, which you can then edit, publish and read.
What you get
Questions that appear only when they apply
Logic shows a question only when an earlier answer matches. A patient who picks tooth pain sees where it hurts and how long it has lasted. A patient on a check-up does not have to scroll past those questions, and your reception does not have to sort out irrelevant answers later.
Logic and pages
Show a follow-up only when it applies, split a long form into pages, or show one question per screen.
Results you can read
A chart for every question, averages and NPS for scales, the order of a ranking, a table of every answer and a CSV.
How it works
- Step 1
Try the sample above, then press Use this template, or describe your own form to the chat.
- Step 2
Change any question by hand or ask the assistant ("add a question about price", "translate it to Spanish"), with a live preview.
- Step 3
Publish, share the link or QR code, and read the answers as they arrive. You get an email for each one.
Who uses it
Solo general dentist opening a second location
You want every new patient to arrive with the same contact details, reason for visit and insurance information, without your front desk retyping paper forms into the practice system.
Practice manager at a busy family dental clinic
Your waiting room fills with paper clipboards and half-filled forms. A link and QR code on the reception screen let patients complete the form on their phones before they sit down.
Dentist who sees many anxious adults
An anxiety scale on the form and a short question about past bad experiences help you plan a gentler first visit, shorter appointments or a conversation before treatment starts.
Questions
Can I ask about medical history and medications on this form?
You can add those questions in the chat, but you are responsible for what you collect and how you store it. Ask only what your clinical team needs for a first visit, and check your local rules on health information before you publish.
Does the form check whether an insurance plan is active?
No. The form records the insurance provider and member ID that the patient types in. Verifying eligibility happens in your own billing or practice system.
How do I receive the answers?
Each response can be sent to an email address you choose. The results page shows charts and can be exported as a CSV, so you can copy the details into your practice software.
Can patients book an appointment or pay a deposit through the form?
No. The tool has no payment step and no booking calendar. You can add a request form where patients ask for a visit, and your team confirms the time by phone or email.
Can I limit how many people fill in the form?
Yes, a response limit can be set, which is useful if you only want the form open for a set number of new patients in a month or during a campaign.