Green Cove Dental

1

Your Details* This field is required.

Full Name

Please enter your email

Please enter a phone number

2

Do you have dental insurance?* This field is required.

YESNO

3

Is the patient an adult, a child or family (more than a single person in the same household seeking coverage)?* This field is required.

Adult

Child

Family

4

When was you last cleaning?* This field is required.

6 months ago

More than 6 months ago

More than 1 year ago

More than 2 years ago

More than 5 years ago

5

How many times a day do you brush?* This field is required.

2 x a day

1 a day

I forget

6

Do you floss your teeth?* This field is required.

Yes I floss before I go to bed

No I don’t floss

Sometimes I floss

7

Do you currently have lots of sensitivity when drinking and eating sweets?* This field is required.

YESNO

8

When you wake up do your jaw and face muscles hurt, have you been told you grind your teeth?* This field is required.

YESNO

9

Are you interested in whitening because of stains?* This field is required.

YESNO

10

Are you missing a tooth and would like options to replace that tooth to get your smile?* This field is required.

YESNO

11

Are you interested in implants or implant dentures?* This field is required.

YESNO

12

Are you interested in straightening your teeth?* This field is required.

YESNO

13

Have you ever had a deep cleaning or surgery on your gums?* This field is required.

YESNO

14

Thank you for filling out this questionnaire!

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