Dentist and clinics

Dental history in steps

A new-patient form in three short steps: you, your teeth, then your health. Each step is easy to finish. This form uses FillKite Pro.

What is in this form

Your name (required)
Email (required)
Date of birth (required)
Do you have…
How often do you brush? (required)
Do you floss?
Do you take regular medication? (required)
Which medication? (required)
Any allergies?
What are you allergic to?

How the conditional logic works

This form shows or hides fields as people answer, so everyone sees only what matters to them.

“Which medication?” appears only when “Do you take regular medication?” is “Yes”.
“What are you allergic to?” appears only when “Any allergies?” is “Yes”.

What FillKite Pro adds

This form uses multi-step, logic, which need FillKite Pro. You can try it here for free. The download works on a site that has FillKite Pro.

Questions

About this form

Is the dental history in steps form free?

You can try it here for free. The form uses multi-step, logic, which need FillKite Pro, so the download works on a site that has FillKite Pro.

Is anything I type saved?

No. This demo runs in test mode: FillKite checks your answers like a real form, but nothing is saved and no email is sent.

How do I use this form on my site?

Install FillKite, download the form with the button on this page, then go to FillKite → Import → From a FillKite file and choose the file. After importing, open it in the builder, change anything you like and add it to a page.

Does this form use conditional logic?

Yes. 2 fields or notices show only when earlier answers call for it. “Which medication?” appears only when “Do you take regular medication?” is “Yes”.

What fields does it have?

It has 10 fields: Your name, Email, Date of birth, Do you have…, How often do you brush?, Do you floss?, Do you take regular medication?, Which medication? and more.

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Conditional logic. Smokers and coffee drinkers get extra advice, and past sensitivity asks which kind.

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FillKite Pro

Do more with every form.

FillKite Pro adds steps, uploads, live totals, quizzes, polls and more to the same builder.

Dental history in steps