Dental new patient form - Illustrated landing

First-visit paperwork for a dental practice: contact details, reason for the visit, dental history, medical flags and insurance. A brand-colour landing page with a hero, illustrated background and a card for each section.

About 5 min to complete. dental, new patient, intake, illustrated.

Questions in this template

1. Patient name
2. Date of birth
3. Mobile number
4. Email
5. What brings you in?
6. How strong is the pain right now?
7. When did you last see a dentist?
8. Have you had any of these?
9. Do any of these apply to you?
10. Tell us about the allergy
11. Do you have dental insurance?
12. Insurance provider
13. Member ID

Related templates

• Patient intake
• Appointment request
• Weekly wellness check-in
• Dental new patient form