Smart Intake Form Builder
Form structure11 fields · adaptive branching
1
Full legal name
textrequired
2
Date of birth
textrequired
3
Mobile number
textrequired
4
Email address
textrequired
5
Do you have dental insurance?
radiobranches on "Yes"
6
Do you have diabetes?
radiobranches on "Yes"
7
Are you currently taking any medications?
radiobranches on "Yes"
8
Do you have any drug allergies?
radiobranches on "Yes"
9
Do you experience dental anxiety?
radio
10
I consent to treatment and authorize Crown to bill my insurance.
checkboxrequired
11
Patient signature
signaturerequired
Form settings
eSignature required
Pre-fill from prior visit
Send via SMS link
HIPAA-secure submission
Expire after 48 hours
Completion rate
94%
Last 90 days · 1,204 forms sent