About this template
Streamline your clinic's check-in process with this comprehensive Dental Patient Information Form. Designed specifically for dental practices, this form allows new patients to submit their essential contact details, primary and secondary dental insurance information, emergency contacts, and referral sources securely online before stepping into your office.
Collecting this information in advance eliminates messy paperwork, reduces lobby wait times, and ensures your practice management system is populated with accurate, legible data from day one. Patients can conveniently complete the form from any device, setting the stage for a smooth, professional visit and allowing your administrative staff to focus on patient care rather than data entry.
Key features
- Collect complete contact and personal details before the appointment
- Gather primary and secondary dental insurance data effortlessly
- Track referral sources to understand what drives your practice growth
- Secure electronic sign-offs and policy acknowledgments
- Eliminate paper clipboards and manual data entry errors
Use cases
- New patient onboarding for private dental practices
- Annual patient information updates and record renewals
- Specialist dental clinic consultations and orthodontics intake
What this form collects
- Full Name (Short answer)Enter your first, middle, and last name.
- Preferred Name / Nickname (Short answer)What would you like us to call you during your visit?
- Date of Birth (Date)Enter your date of birth.
- Sex (Multiple choice)Select your biological sex or gender identity.
- Phone Number (Short answer)Enter the best phone number to reach you for appointment reminders.
- Email Address (Short answer)We will use this to send appointment confirmations and receipts.
- Home Address (Paragraph)Enter your street address, city, state, and ZIP code.
- Insurance Company Name (Short answer)Name of your insurance provider.
- Group Number (Short answer)Found on your insurance card.
- Employer (Short answer)Name of the employer providing the insurance plan.
- Subscriber Full Name (Short answer)Name of the primary policy holder.
- Subscriber Date of Birth (Date)Date of birth of the primary policy holder.
- Relationship to Patient (Dropdown)How is the subscriber related to the patient?
- How did you hear about us? (Dropdown)Select the main source that led you to our practice.
- Terms and Conditions Acceptance (Multiple choice)I certify that I have read and understand the above information to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
- Signing Date (Date)Today's date.
- Signature of Patient or Responsible Party (Short answer)Type your full legal name as an electronic signature.
FAQ
How can I share this form with my patients?
You can easily share the Google Form link via email confirmation, embed it on your practice website, or send it via SMS reminder prior to their appointment.
Can I customize the questions to fit my practice's needs?
Yes! Once you generate the form, you have full control in Google Forms to add, remove, or edit any questions, including adding your clinic's logo and custom branding.
Where are the patient submissions stored?
All submissions are automatically organized in a secure Google Sheet linked to your form, making it easy to review responses and export data.
Is this form mobile-friendly for patients?
Yes, Google Forms automatically optimize for mobile devices, allowing patients to complete their intake forms smoothly on smartphones or tablets.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.