Free Dental Clinic Checklist Form Template
Dental Clinic Checklist Form
Ensure a smooth and efficient visit to our dental clinic by completing this checklist before your appointment.
Name
Date of Birth
Phone number
Address
Preferred Contact Method
-
Phone
-
Email
-
Mail
Last Dental Visit
Existing Dental Issues
Insurance Provider
Reason for Appointment
Appointment Date & Time
Pre-Visit Checklist
|
Task |
Checkbox |
Notes |
|---|---|---|
|
Call or text to confirm your appointment. |
|
|
|
Bring your insurance card. |
|
|
|
Provide details of your insurance provider. |
|
|
|
Fill out the medical history form. |
|
|
|
List any current medications |
|
|
|
Note any dental issues (pain, sensitivity, etc.) |
|
|
|
Bring sunglasses or hat if sensitive to light. |
|
|
|
Wear comfortable clothing for your visit. |
|
|
|
Arrange transportation if necessary. |
|
|
After Your Visit
|
Task |
Checkbox |
Notes |
|---|---|---|
|
Schedule your next appointment. |
|
|
|
Follow any post-visit care instructions provided by the dentist. |
|
|
Thank you for your submission!
We appreciate you taking the time to submit.
Create free forms at Template.net
