Pediatric Dental First Visit Intake Form

Pediatric Dental First Visit Intake Form — Form Fields

This healthcare template includes 13 fields. Parents complete an initial dental intake form before their child's first dental appointment. Free to customize and use on ZenBuild.

• Child's Full Name (text, required)
• Date of Birth (text, required)
• Parent or Guardian Name (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Pediatrician Name (text, required)
• Previous Dental Visits? (dropdown selection, required) — options: Yes, No - First Visit Ever
• How does child clean teeth? (dropdown selection, required) — options: Parent brushes, Child brushes with supervision, Child brushes independently, Not established
• Fluoride Toothpaste Used? (dropdown selection, required) — options: Yes, No
• Does child use a pacifier or thumb? (dropdown selection, required) — options: Yes, No
• Dietary habits - drinks sugary drinks daily? (dropdown selection, required) — options: Yes, Occasionally, No
• Dental Concerns to Discuss (text, optional)
• Parent acknowledges office financial policy (checkboxes, required)