Use our readymade template to create this Google form. Customize it further using our form builder.
Create your intake form
- Use prebuilt template to create a dental intake form for your dental practice
- Collect patient, demography, emergency contact details, dental history
- Collect dental insurance information and consent for use and disclosure of PHI
- Allow patients to upload prescriptions and list current medications
- Get signatures for consent for treatment and notice of privacy practices
Collect responses from your patients
| Patient Signature | user input |
| Date signed | 2023-08-08 |
| What is the reason for today's visit? | dental exam |
| Check if you have any of the problems listed below | Toothache,Pain, clicking or popping of jaw |
| Do you or have you had any of the following? | Dentures,Braces |
| How important is your dental health to you? | user input |
| Where would you rate your current dental health? | user input |
| How satisfied are you with the appearance or your teeth? | user input |
| Are you satisfied with the way your smile looks? | Yes |
| Are you currently in good health? | Yes |
| Are you currently taking any medications? | Yes |
| List medications you are currently taking | user input |
| Do you have any allergies? | No |
| List any allergies you may have | user input |
| Do you presently or have you ever had: | Anemia,Diabetes |
| Patient Signature | user input |
| Date Signed | 2023-08-08 |
- Pre-populate patient details from your booking system to reduce errors
- Send an email invitation with a secure link for patients to complete their intake
- Allow patients to save their progress and complete their form at a later time
- Set up an email template and send invitation emails to multiple patients with ease
- Send an email to the patients with a copy of their response when they submit the form
Track patient responses in Google Sheets
- Export patient responses to Google Sheets for easy record-keeping
- Create a custom workflow and manage your patient intake efficiently
- Use pre-built reports to easily keep track of patient progress over time
- Receive a copy of the response by email when a patient submits the intake form
- Use data in Google Sheets to integrate with dental practice management systems for seamless data transfer
HIPAA compliance
| Date signed: | 8/8/2023 |
| What is the reason for today's visit?: | dental exam |
| Check if you have any of the problems listed below: | Toothache, Pain, clicking or popping of jaw |
| Do you or have you had any of the following?: | Dentures, Braces |
| Are you satisfied with the way your smile looks?: | Yes |
| Are you currently in good health?: | Yes |
| Are you currently taking any medications?: | Yes |
| List medications you are currently taking: | user input |
| Do you have any allergies? : | No |
| List any allergies you may have: | user input |
| Do you presently or have you ever had:: | Anemia, Diabetes |
| Date Signed: | 8/8/2023 |
- Create a HIPAA compliant intake form to safely collect, store and access patient responses
- Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
- Mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
July 27, 2023
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— Royal Bush
July 23, 2023
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February 16, 2024
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October 31, 2023
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July 12, 2023
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November 27, 2023
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July 10, 2023
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