New Patient Intake Form

About this form

The new patient intake form is a patient intake document used by dental practices. Comprehensive patient registration including personal details, emergency contacts, and preferences. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 16 fields:

• Full Legal Name — Text
• Date of Birth — Date
• Social Security Number (last 4 digits) — Text
• Gender — Single choice
• Home Address — Text
• City, State, ZIP — Text
• Phone Number — Text
• Email Address — Text
• Emergency Contact Name — Text
• Emergency Contact Phone — Text
• Preferred Contact Method — Single choice
• Do you have dental insurance? — Single choice
• Insurance Provider — Text
• Patient Signature — Signature
• Date — Date

When practices use it

Dental teams typically attach this form to the new-patient workflow, sending it before the first appointment so the front desk has complete records on arrival. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists (English, Español, 中文, Tagalog, Tiếng Việt, العربية, Français, 한국어, Русский, Português).
• Share a secure link with the patient, or download a print-ready PDF.