DentRx Health · Pre-Visit Intake

Let’s get ready for your visit

This quick form helps your dental and DentRx care team understand your overall health, so your treatment can be planned safely. It takes about 5 minutes.

Your information is private and shared only with your care team to support your treatment.

About you

Tell us who you are and how to reach you.

Used to match your records and send appointment reminders.

Your visit

Where you’re being seen and what brings you in.

Insurance

Optional — helps us check coverage for monitoring services.

Health history

Check anything that applies. These conditions can affect healing and your treatment plan.

Recent readings

Optional — only if you already monitor these at home.

Consent & signature

Please review and confirm before submitting.

Thank you — your intake is ready

We’ll review this before your appointment.

Send to DentRx

Submit your intake directly to your care team.

Save a copy

Download your answers for your own records.

Copy for PREMO intake

Copy a clean text block to paste into a PREMO intake document.

Email my dental office

Open an email with your intake to send to the practice.