Dental History

Dental History
Primary reason for Dental Appointment

ExamCleaningEmergencyConsultationSecond Opinion
Do you have a specific dental problem?

YesNo
If yes, please describe
Are your teeth sensitive to:

ColdHotSweetBitingTouching
Are you in pain?

YesNo
How would you describe your present dental health?

ExcellentGoodFairPoor
Do you think you have active decay/cavities?

YesNo
Do you think you have gum disease?

YesNo
Do your gums bleed?

YesNo
Do you have bad breath?

YesNo
Have you ever been taught to control dental disease?

YesNo
How often do you brush?
Clicking, popping, or discomfort in the Jaw joint?

YesNo
Do you clench or grind your teeth?

YesNo
TMJ(Jaw Point) Therapy?

YesNo
Do you have any sores or growths in your mouth?

YesNo
Have you ever had gum surgery?

YesNo
Braces?

YesNo
Floss?
To make your visit as comfortable as possible. I'd like to ask you a few questions. In our office, we believe that the person attached to the teeth is important, if not more important than the teeth. The more we know about your needs, desires and concerns, the more we can provide you with what you want.
Are you pleased with the appearance of your teeth?

YesNo
Would you like information on teeth whitening?

YesNo
Please describe any changes you would like to make in the appearance of your teeth?
Have your past dental experiences always been positive?

YesNo
What did you like the most:
What did you like the least?
Do you have any fear of dental treatment?

YesNo
Describe your fear or bad experience, if any:
Is there anything we can do to make your visit more comfortable?
How much dental work do you feel that you need?

MajorSomeVery Little
If you had the perfect smile and best dental health, what would it do for you?
Is there anything standing in your way to achieve perfect oral health?
SUGAR LAND DENTAL PAYMENT POLICY
Sugar Land Dental requires payment for services at the time of service, or when treatment is rendered. We accept many types of payment including cash, checks and credit cards. We have also contracted with a national credit agency in which you can apply for third party financing for services over $500.00.

Sugar Land Dental will file, on your behalf, your primary dental insurance coverage for services performed. These claims are filed as a courtesy to our patients and do not ensure insurance coverage. In the event insurance claims are denied or not paid in full, the patient will be responsible for payment of services.

Please sign below to indicate your understanding of Sugar Land Dental's payment policy. Additionally, please feel free to contact us if you have any questions concerning our payment policy.
ANY APPOINTMENT CHANGE OF LESS THAN 48 BUSINESS HOURS NOTICE WILL BE SUBJECT TO A CANCELLATION FEE AND/OR PREPAYMENT TO RESERVE FUTURE APPOINTMENTS
Patient Name:
Signature of Patient or Responsible Party:

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Date:

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Dental History

SUGAR LAND DENTAL PAYMENT POLICY