King Family Dental Care, P.A.
Dental Survey
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of previous dentist
Address of previous dentist
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of previous dentist
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for leaving previous dentist
Check any of the following that apply to you TODAY or in your past:
*
Toothache
Trouble Chewing
Pain in jaw joints
Grind your teeth
Dental implants
Pre-medicate with antibiotics before dental treatment
Mouth ulcers or sores or growths
Gums bleed when you brush or floss
Nervous about dental treatment
History of fainting during dental treatment
Periodontal surgery
Orthodontic treatment
Bad experience with previous dentist
Diagnosed with Periodontal Disease
Are you happy with your smile?
*
Please Select
Yes
No
Do you wish your teeth were whiter?
*
Please Select
Yes
No
Do you feel that you have crowded or overlapped teeth?
*
Please Select
Yes
No
Would you be interested in straightening your teeth?
*
Please Select
Yes
No
Would you like to learn about how INVISALIGN clear retainers can be used to straighten your teeth?
*
Please Select
Yes
No
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: