Dental History

Dental History
Primary reason for Dental Appointment

Exam Cleaning Emergency Consultation Second Opinion
Do you have a specific dental problem?

Yes No
If yes, please describe
Are your teeth sensitive to:

Cold Hot Sweet Biting Touching
Are you in pain?

Yes No
How would you describe your present dental health?

Excellent Good Fair Poor
Do you think you have active decay/cavities?

Yes No
Do you think you have gum disease?

Yes No
Do your gums bleed?

Yes No
Do you have bad breath?

Yes No
Have you ever been taught to control dental disease?

Yes No
How often do you brush?
Clicking, popping, or discomfort in the Jaw joint?

Yes No
Do you clench or grind your teeth?

Yes No
TMJ(Jaw Point) Therapy?

Yes No
Do you have any sores or growths in your mouth?

Yes No
Have you ever had gum surgery?

Yes No
Braces?

Yes No
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?

Yes No
Would you like information on teeth whitening?

Yes No
Please describe any changes you would like to make in the appearance of your teeth?
Have your past dental experiences always been positive?

Yes No
What did you like the most:
What did you like the least?
Do you have any fear of dental treatment?

Yes No
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?

Major Some Very 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