# Dental patient intake form: medical history, dental history and insurance [Home](/) / [Document guides](/documents) / [Patient intake form](/documents/patient-intake-form) / Dental intake form By [Arthur Teboul](/authors/arthur-teboul), Founder, DokuTrak. Published 2026-11-06, updated 2026-11-06. > **In brief:** A dental patient intake form collects a new patient’s contact and dental insurance details, a medical history focused on what changes dental care, such as blood thinners, heart conditions and allergies to anesthetics, and a dental history. The office adds a privacy notice acknowledgment and a request for prior X-rays. ## What is a dental patient intake form? In practice, **a dental patient intake form** is a medical intake narrowed to the mouth. Instead of a full review of systems, it asks the health questions that change what happens in the chair: bleeding risk, anesthesia, infection risk and medications that affect bone or gums. It then asks about the teeth themselves, from the last cleaning to jaw pain. Dental offices also handle insurance differently from medical clinics. Dental plans are often separate policies with their own subscriber, group number and yearly maximum, and many families carry two, so the form asks for both and who the subscriber is on each. Like any provider with a direct treatment relationship, the office gives the patient its Notice of Privacy Practices at the first visit and makes a good-faith effort to get a signed acknowledgment ([45 CFR 164.520, Notice of privacy practices](https://www.law.cornell.edu/cfr/text/45/164.520)). ## Who sends it, and when The dental office creates it and the front desk sends it, often with the appointment confirmation. The patient fills it in, or a parent or guardian for a child. The dentist or hygienist reviews the health section with the patient before any treatment and initials the update at each recall visit. ## Where to get a dental patient intake form 1. Download the template below and add the office name, address and phone. 2. Send it with the confirmation and ask the patient to photograph both sides of each dental insurance card. 3. Ask for the previous dentist’s name and phone so the office can request recent X-rays. 4. At the first visit, the clinician reviews the health answers with the patient and notes follow-up questions. ## Wrong files people send instead - The medical insurance card sent instead of the dental card. - A blank subscriber field when the patient is a dependent on a spouse’s or parent’s plan. - Blood thinners or bone medications left off because the patient thought they did not matter to a dentist. - Waiting for the patient to collect old X-rays when the office could request them directly. ## Health questions that change dental treatment Each question on the health half earns its place by changing something the dentist does. When a patient answers yes, the clinician follows up in person. | Question | What a yes changes in the chair | | --- | --- | | Blood thinners or a bleeding disorder | Planning for extractions, deep cleanings and surgery | | Heart valve, heart condition or joint replacement | The dentist asks whether the patient’s physician recommends antibiotics before treatment | | Allergies to local anesthetic, penicillin, latex or metals | Choice of anesthetic, antibiotic, gloves and materials | | Bone medications, such as drugs for osteoporosis | A conversation before extractions or implants | | Diabetes | Gum health and healing | | Pregnancy or nursing | Timing of X-rays and elective work | | Radiation to the head or neck | Dry mouth and bone healing after extractions | | Tobacco or vaping | Gum disease screening and healing after surgery | ## Dental history questions The second half asks about the mouth. Short yes or no lines work better than open boxes, because patients actually answer them. - Date of the last cleaning and the last X-rays, and the previous dentist’s name and phone. - Main reason for the visit, such as a checkup, pain, a broken tooth or a cosmetic question. - Sensitivity to hot or cold, bleeding gums, jaw pain or clicking, grinding, dry mouth. - Past orthodontics, crowns, bridges, implants or dentures. - Anxiety about dental treatment, and what helps. ## Dental insurance fields and coordination of benefits **Coordination of benefits** means sorting out which of two plans pays first and which pays the rest. The office cannot do it without both plans and both subscribers on file. Ask for carrier, subscriber name and date of birth, subscriber ID, group number and employer for each plan, and the patient’s relationship to each subscriber. A child covered by both parents is the usual case where a second plan applies. ## Getting X-rays from the previous dentist Recent X-rays from the last office can spare the patient a new set. Because the new dentist needs them for treatment, the previous office may send them without the patient’s authorization ([45 CFR 164.506, Treatment, payment and health care operations](https://www.law.cornell.edu/cfr/text/45/164.506)). The patient can also request a copy directly; the provider must act on that request within 30 days, with one extension of up to 30 days ([45 CFR 164.524, Right of access](https://www.law.cornell.edu/cfr/text/45/164.524)). A signed authorization is only needed for uses other than treatment, payment and operations, such as sending records to a lawyer, and that uses a separate [HIPAA release form](/documents/hipaa-release-form) ([45 CFR 164.508, Authorizations](https://www.law.cornell.edu/cfr/text/45/164.508)). ## Signatures the office keeps Close the form with the papers the office files, each on its own line. The **privacy notice acknowledgment** is the patient’s signature confirming they received the office’s notice; if the patient will not sign, the office notes its attempt and the reason ([45 CFR 164.520, Notice of privacy practices](https://www.law.cornell.edu/cfr/text/45/164.520)). The financial policy and the consent to treatment come from the office’s own policy and state rules. The general [patient intake form](/documents/patient-intake-form) guide explains how these papers differ. ## The template: Dental new patient form **Not advice.** This page is general information, not tax, legal or HR advice. Rules change: check the cited source and ask your own professional before you rely on it. Last reviewed October 25, 2026. Print it on the office letterhead or turn it into a fillable PDF. The clinician reviews the health section with the patient at the first visit and at each recall. Drop the child block for adult patients. ```text [Dental office name] | [Address] | [Phone] NEW DENTAL PATIENT REGISTRATION First visit: [MM/DD/YYYY] | Dentist: [Name] Patient Name: [ ] Preferred name: [ ] Date of birth: [ ] Address: [ ] Phone: [ ] Email: [ ] Preferred language: [ ] Emergency contact and phone: [ ] Primary dental plan Carrier: [ ] Subscriber name: [ ] Subscriber date of birth: [ ] Subscriber ID: [ ] Group number: [ ] Employer: [ ] Your relationship to the subscriber: [self / spouse / child / other] Second dental plan (optional) Carrier: [ ] Subscriber name and date of birth: [ ] Subscriber ID: [ ] Group number: [ ] Relationship: [ ] Your health Physician name and phone: [ ]. Medications, including blood thinners and bone medications: [ ]. Allergies to anesthetics, antibiotics, latex, metals or other: [ ]. Do you have or have you had: [ ] heart valve or heart condition [ ] joint replacement [ ] bleeding disorder [ ] diabetes [ ] high blood pressure [ ] hepatitis [ ] radiation to head or neck [ ] other: [ ]. Pregnant or nursing: [ ] yes [ ] no. Tobacco or vaping: [ ] yes [ ] no. Your teeth Reason for visit: [ ]. Last cleaning: [ ] Last X-rays: [ ] Previous dentist and phone: [ ]. Do you have: [ ] sensitivity [ ] bleeding gums [ ] jaw pain or clicking [ ] grinding [ ] dry mouth [ ] dentures or implants [ ] past orthodontics. Anything that makes dental visits hard for you: [ ] Child patient (optional) Parent or guardian name and phone: [ ]. Who brings the child to visits: [ ]. Thumb sucking or pacifier use: [ ] yes [ ] no. Financial policy and consent to treatment I have read the financial policy and I consent to dental examination and treatment. Acknowledgment of the Notice of Privacy Practices (own signature line) I received [Dental office name]’s Notice of Privacy Practices on [MM/DD/YYYY]. Signature: ____________________. Office use, if not signed: good-faith effort made and reason: ____________________ Signature of patient, parent or guardian: ____________________ Date: [MM/DD/YYYY] Reviewed by: [Clinician initials] Date: [MM/DD/YYYY] ``` Download: [Word](https://dokutrak.com/downloads/pseo-v2/f6-document-guides/patient-intake-form/dental.docx) · [PDF](https://dokutrak.com/downloads/pseo-v2/f6-document-guides/patient-intake-form/dental.pdf) ## Questions people ask ### What should a dental new patient form include? Contact details, an emergency contact, dental insurance for each plan, a medical history focused on bleeding, heart conditions, allergies and medications, a dental history, and the signed acknowledgments the office keeps. ### Does the patient sign a HIPAA form at a dental intake? The patient usually signs an acknowledgment that they received the office’s privacy notice, which the office must try in good faith to obtain ([45 CFR 164.520, Notice of privacy practices](https://www.law.cornell.edu/cfr/text/45/164.520)). That acknowledgment is not an authorization to send records to others. ### Does the office need a release to get X-rays from my last dentist? No. One provider may send records to another for treatment without the patient’s authorization ([45 CFR 164.506, Treatment, payment and health care operations](https://www.law.cornell.edu/cfr/text/45/164.506)). Giving the new office the previous dentist’s name and phone is enough to start. ## Sources - [45 CFR 164.520, Notice of privacy practices](https://www.law.cornell.edu/cfr/text/45/164.520): A provider with a direct treatment relationship gives the notice at first service and makes a good-faith effort to obtain written acknowledgment, documenting the reason if it is not obtained. - [45 CFR 164.506, Treatment, payment and health care operations](https://www.law.cornell.edu/cfr/text/45/164.506): A covered entity may disclose protected health information for the treatment activities of a health care provider. - [45 CFR 164.524, Right of access](https://www.law.cornell.edu/cfr/text/45/164.524): A provider must act on an access request within 30 days, with one extension of up to 30 days. - [45 CFR 164.508, Authorizations](https://www.law.cornell.edu/cfr/text/45/164.508): Uses and disclosures outside those the rule permits require a valid authorization with its core elements. ## More on this topic - [Patient intake form](/documents/patient-intake-form) - [HIPAA release form](/documents/hipaa-release-form) - [Patient intake document collection](/blog/patient-intake-document-collection) ## About the author Arthur Teboul (Founder, DokuTrak) is building DokuTrak after watching professionals lose hours chasing clients for documents over email. [Arthur Teboul](/authors/arthur-teboul). How this page was made (methodology): it is built from the primary sources listed under Sources, and every rule and figure on it links to the source it comes from. Last updated October 25, 2026. Spotted an error or a rule that changed? [Contact us](/contact).