First Name

Last Name

Middle Initial

Email

Phone

How May We Help You Today?

How Many Times Do You Floss Per Week?

How Many Times Do You Brush Per Day?

Your Current Dental Health Is:
GoodFairPoor

Require Antibiotics Before Dental Treatment?
YesNo

Are You Currently In Pain?
YesNo

Have You Ever Had Gum Treatment?
YesNo

Do You Now Or Have You Had Any Pain/Discomfort In Your Jaw Joint?
YesNo

Are You Under Stress? (New Job, Moving, Relationships, etc.)
YesNo

Do You Like Your Smile?
YesNo

Is There Anything You Would Like To Change About Your Smile?
YesNo

Are You Happy With The Color Of Your Teeth?
YesNo

Do Your Gums Bleed?
YesNo

Are Your Teeth Sensitive To Heat, Cold Or Anything Else?
YesNo

Have You Lost Any Teeth?
YesNo

Have You Ever Had A Difficult Problem With Any Previous Dental Work?
YesNo

Have You Ever Had Any Unfavorable Dental Experiences?
YesNo

When was your last dental cleaning?

When was your last dental visit?

Why did you leave your previous dentist?

How can we accommodate you better during your dental visit?