Smile Evaluation

Dental History
Do you have any present dental complaints?

YesNo
What?
When was your last full-mouth X-ray taken?
Where?
When was your last cleaning?
Where?
Have you ever been instructed in the prevention of decay?
Have you ever been instructed in caring for your gums?
Remarks
I consent to whatever dental procedures and anesthetics are necessary for the treatment of the above named patient. I also agree to assume full financial responsibility for all treatment rendered.
Signature*

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Date*

MonthDayYear
Date
*Once the form is submitted, a copy will be sent to your email automatically.
Should be Empty:

Health History