For Reducing Dental Fears @ Town & Country Dental

Providing 5-Star, Enjoyable Experiences

We have helped thousands of fearful patients change their dental health trajectory through our unique, concierge approach to care. Our Team will treat you like family so enjoyable experiences just happen naturally. Complete this form to let us know how we can provide a 5-Star Experience for YOU!

What is your fear, anxiety and avoidance level about seeing a dentist for treatment?*

	1	2	3	4	5	6	7

1 is Enjoy, 7 is High Avoidance

What is your fear, anxiety and avoidance level about going to a preventive visit and getting your teeth cleaned?*

	1	2	3	4	5	6	7

1 is Enjoy, 7 is High Avoidance

An Anxious Patient's Success Story...
Please check all of your barriers to regular preventive care, dental treatment and ultimately, your good dental health:*

I become focused on other priorities.Dental care is difficult to afford. ("Dental disease is more difficult to afford." DrW)I don't have good preventive home care habits.I don't schedule regular preventive dental visits.I avoid getting my teeth cleaned.I avoid going to see the dentist.Other (please note below)
Overall Health of Your Teeth (select one):*

ExcellentGoodFairPoor
Overall Health of Your Gums (select one):*

ExcellentGoodFairPoor
Are you happy with your smile appearance?*

I am very happy with my smile.Yes, but my smile could be improved.No, I am self-conscious about my smile.
Please describe why you fear and/or avoid dental treatment appointments. Also tell us everything that has made you uncomfortable before or during past appointments:*
Our Patients Comfort & Experiences...
Would you like to schedule a Free Introductory Call, Zoom or 2nd Opinion with Dr. Wegner and Team?*

Yes, I am ready at this time.Yes, but contact me in 4 weeks.No, this does not look like a good fit for me.No, my past experiences and fear will only be overcome by pain and an emergency.Other (Please note below)
Is there anything else you'd like Dr. Wegner or Our Team to know that may enable them to make you more comfortable and help you prevent future dental disease/expense?
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Best times to contact you:
Our team is committed to treating you
like family!

Be sure to let a staff member know if there is anything we can do to improve your experiences in our office!
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Providing 5-Star, Enjoyable Experiences

An Anxious Patient's Success Story...

Our Patients Comfort & Experiences...