Dental Screening Form

Helps dental professionals quickly assess a patient's oral health and needs ahead of an appointment.

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Full Name

First Name

Last Name

Date of Birth

Phone Number

Email Address

Address

Street Address

City

State / Province

ZIP / Postal Code

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Are you currently experiencing any of the following dental concerns? (Check all that apply)

Tooth pain Bleeding gums Sensitivity Bad breath Jaw pain None

Please provide details on any dental concerns you have:

Do you have any known allergies or medical conditions? If yes, please provide details:

Are you currently taking any medications? If yes, please provide details:

Do you have dental insurance?

Yes No

If yes, please provide the name of your dental insurance provider:

Please indicate your preferred appointment date and time:

Date

Time

Do you give consent for a dental screening and necessary treatment?

Yes No

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