New Patient Dental Questionnaire
Dr. Hwang and his team would like to help each patient reach their dental goals. Please take a few moments and provide us the following valuable information. I entered this practice to obtain: (check all that apply)
Patient's Name
First Name
Last Name
Comprehensive Exam of my entire mouth and a consultation with Dr. Hwang and his team concerning my treatment options.
Smile Design Consultation to learn more about my cosmetic treatment options
Emergency Exam for a specific area of concern.
Any Pain?
Yes
No
Please describe
2nd
Opinion
concerning treatment options presented elsewhere.
Other
(please explain)
I would rate the value I place on my oral health as:
High Importance
Moderate Importance
Low Importance
I would rate the condition of my teeth and gums as
Very Good
Good/Acceptable
Need Treatment
I would rate my previous dental experiences and quality of care as
Above Average
Acceptable/Average
Below Average
I have concerns in pursuing future dental treatment
Yes
No
My concerns are
Fearful of Treatment
Financial
Scheduling
I consider my smile
Very Appealing
Nice/Acceptable
Needs Improvement
Is there any further information about you that would help us assist you more thoroughly?
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