Patient intake form — Orilla Clinic (concept demo)

About you

As it appears on your passport or ID.

First name

Last name

Date of birth

Country you live in most of the year

Mobile number Optional

Emergency contact OptionalSomeone we can call if you feel unwell after treatment.

Teeth and skin

No wrong answers here. Dentists have heard “about ten years ago” before.

When did you last see a dentist?

How nervous are you about treatment? 1 is calm, 5 is very nervous.

What would you like us to look at? Optional

Have you had injectable aesthetic treatment before?

NeverIn the last 6 monthsLonger ago

Consent

Two of these are needed for us to treat you. Two are up to you.

The information I’ve given is accurate, and I’ll tell the clinic if my health or medication changes.

I agree that Orilla Clinic keeps my health record for the purpose of my treatment, as set out in the privacy notice.

Optional: the clinic may take clinical photos to plan and document my treatment. They are never published without asking me again. Optional: remind me when my next check-up or hygiene visit is due.

Type your full name to signSigned on .

Done. Thank you.

Your clinician will have this before your visit.

On a live site the form would now be filed against your patient record and anything urgent, such as an allergy, flagged on the doctor’s day list. Here it stays in this browser only.

Book a visit or see what the clinic’s system does with a completed form.