A dental new patient form to send with the booking

Updated 2026-10-30

Half of a first dental visit goes on forms and small talk. I would rather have the basics before the patient sits down. One link, sent with the booking, tells the team why they are coming and what worries them.

How it works

  1. The patient gives a name, birth date and mobile number.
  2. They say what they want help with: a clean, pain, a cosmetic change or a second opinion.
  3. They share their brushing habits, mouth concerns and how nervous they feel.
  4. They list health flags and medicines, and name their last dentist so you can ask for X-rays.

What the patient's AI would ask

"What would you like help with?" Then "Do you have bleeding gums or sensitive teeth?" Then "How nervous do you feel, from 1 to 5?" It shows every answer and sends only after a yes. Read about agent-fillable forms.

Good to know

Read the nerves score first, then the pain answers. Check your local privacy rules before collecting health data. This is a form, not medical advice.

Pair it with a patient registration form for the paperwork side. A patient referral form helps when a dentist sends someone on. More in forms for clinics.

Questions

Why ask how nervous a patient feels?

A nervous patient often needs a longer first visit and a calmer start. The nerves_score answer lets the team plan that before the patient is in the chair.

Can parents fill this in for a child?

Yes. The last question collects a parent or guardian contact. A parent can answer for the child, or give the form to their own AI agent, which asks for what is missing.

Do I get insurance details here?

No. The form leaves out insurance and ID numbers on purpose. Collect those in the system your practice already protects, or at the desk.

Try the form

Live demo ยท nothing is saved

Welcome to the practice

A few answers before your first visit help us plan your time in the chair. Nervous about the dentist? Tell us. We will go at your pace.

What would you like help with? (required)
When did you last see a dentist?
How often do you brush?
Do you have any of these?
How nervous do you feel about dental visits?

1 is calm and 5 is very nervous.

Health matters your dentist should know
Use this templateAll templates

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text
Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Welcome to the practice",
  "description": "A few answers before your first visit help us plan your time in the chair. Nervous about the dentist? Tell us. We will go at your pace.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "mobile_phone",
      "label": "Mobile phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "email_address",
      "label": "Email",
      "type": "email"
    },
    {
      "id": "visit_goal",
      "label": "What would you like help with?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Check-up and clean",
        "Tooth pain",
        "Broken or lost filling",
        "Cosmetic work",
        "Braces or aligners",
        "A second opinion"
      ]
    },
    {
      "id": "last_dentist_visit",
      "label": "When did you last see a dentist?",
      "type": "single_choice",
      "options": [
        "Within the last 6 months",
        "About a year ago",
        "More than 2 years ago",
        "I cannot remember",
        "Never"
      ]
    },
    {
      "id": "brushing_habit",
      "label": "How often do you brush?",
      "type": "single_choice",
      "options": [
        "Twice a day or more",
        "Once a day",
        "Less than once a day"
      ]
    },
    {
      "id": "mouth_concerns",
      "label": "Do you have any of these?",
      "type": "multi_choice",
      "options": [
        "Bleeding gums",
        "Sensitive teeth",
        "Jaw pain or clicking",
        "Grinding at night",
        "Dry mouth",
        "Loose teeth"
      ]
    },
    {
      "id": "nerves_score",
      "label": "How nervous do you feel about dental visits?",
      "type": "rating",
      "help": "1 is calm and 5 is very nervous.",
      "min": 1,
      "max": 5
    },
    {
      "id": "health_flags",
      "label": "Health matters your dentist should know",
      "type": "multi_choice",
      "options": [
        "Heart condition",
        "Diabetes",
        "Pregnancy",
        "Blood thinners",
        "Joint replacement",
        "Allergy to latex or anesthetic",
        "None of these"
      ]
    },
    {
      "id": "medicines_list",
      "label": "Medicines you take",
      "type": "long_text",
      "max_length": 800
    },
    {
      "id": "previous_dentist",
      "label": "Previous dentist, so we can ask for X-rays",
      "type": "short_text",
      "max_length": 250
    },
    {
      "id": "guardian_contact",
      "label": "Parent or guardian name and phone, if under 18",
      "type": "short_text",
      "max_length": 250
    }
  ]
}

Or call the API

bash
curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Welcome to the practice","description":"A few answers before your first visit help us plan your time in the chair. Nervous about the dentist? Tell us. We will go at your pace.","fields":[{"id":"patient_name","label":"Your full name","type":"short_text","required":true,"max_length":150},{"id":"birth_date","label":"Date of birth","type":"date","required":true},{"id":"mobile_phone","label":"Mobile phone","type":"phone","required":true},{"id":"email_address","label":"Email","type":"email"},{"id":"visit_goal","label":"What would you like help with?","type":"single_choice","required":true,"options":["Check-up and clean","Tooth pain","Broken or lost filling","Cosmetic work","Braces or aligners","A second opinion"]},{"id":"last_dentist_visit","label":"When did you last see a dentist?","type":"single_choice","options":["Within the last 6 months","About a year ago","More than 2 years ago","I cannot remember","Never"]},{"id":"brushing_habit","label":"How often do you brush?","type":"single_choice","options":["Twice a day or more","Once a day","Less than once a day"]},{"id":"mouth_concerns","label":"Do you have any of these?","type":"multi_choice","options":["Bleeding gums","Sensitive teeth","Jaw pain or clicking","Grinding at night","Dry mouth","Loose teeth"]},{"id":"nerves_score","label":"How nervous do you feel about dental visits?","type":"rating","help":"1 is calm and 5 is very nervous.","min":1,"max":5},{"id":"health_flags","label":"Health matters your dentist should know","type":"multi_choice","options":["Heart condition","Diabetes","Pregnancy","Blood thinners","Joint replacement","Allergy to latex or anesthetic","None of these"]},{"id":"medicines_list","label":"Medicines you take","type":"long_text","max_length":800},{"id":"previous_dentist","label":"Previous dentist, so we can ask for X-rays","type":"short_text","max_length":250},{"id":"guardian_contact","label":"Parent or guardian name and phone, if under 18","type":"short_text","max_length":250}]}'

JSON definition

json
{
  "title": "Welcome to the practice",
  "description": "A few answers before your first visit help us plan your time in the chair. Nervous about the dentist? Tell us. We will go at your pace.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "mobile_phone",
      "label": "Mobile phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "email_address",
      "label": "Email",
      "type": "email"
    },
    {
      "id": "visit_goal",
      "label": "What would you like help with?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Check-up and clean",
        "Tooth pain",
        "Broken or lost filling",
        "Cosmetic work",
        "Braces or aligners",
        "A second opinion"
      ]
    },
    {
      "id": "last_dentist_visit",
      "label": "When did you last see a dentist?",
      "type": "single_choice",
      "options": [
        "Within the last 6 months",
        "About a year ago",
        "More than 2 years ago",
        "I cannot remember",
        "Never"
      ]
    },
    {
      "id": "brushing_habit",
      "label": "How often do you brush?",
      "type": "single_choice",
      "options": [
        "Twice a day or more",
        "Once a day",
        "Less than once a day"
      ]
    },
    {
      "id": "mouth_concerns",
      "label": "Do you have any of these?",
      "type": "multi_choice",
      "options": [
        "Bleeding gums",
        "Sensitive teeth",
        "Jaw pain or clicking",
        "Grinding at night",
        "Dry mouth",
        "Loose teeth"
      ]
    },
    {
      "id": "nerves_score",
      "label": "How nervous do you feel about dental visits?",
      "type": "rating",
      "help": "1 is calm and 5 is very nervous.",
      "min": 1,
      "max": 5
    },
    {
      "id": "health_flags",
      "label": "Health matters your dentist should know",
      "type": "multi_choice",
      "options": [
        "Heart condition",
        "Diabetes",
        "Pregnancy",
        "Blood thinners",
        "Joint replacement",
        "Allergy to latex or anesthetic",
        "None of these"
      ]
    },
    {
      "id": "medicines_list",
      "label": "Medicines you take",
      "type": "long_text",
      "max_length": 800
    },
    {
      "id": "previous_dentist",
      "label": "Previous dentist, so we can ask for X-rays",
      "type": "short_text",
      "max_length": 250
    },
    {
      "id": "guardian_contact",
      "label": "Parent or guardian name and phone, if under 18",
      "type": "short_text",
      "max_length": 250
    }
  ]
}