Welcome to Our Office
Please answer the following questions so we will know how to provide you with the best possible care
Reason for today’s visit?
Are your teeth sensitive to hot, cold, sweets or pressure?
Is there anything you would like to change with your smile?
now more about: Please check all that apply:
Veneers
Implants
Whitening
Invisalign
Have you ever suffered from prolonged dry mouth?
Yes
No
Have you ever had jaw pain/clicking/popping?
Yes
No
Do you wear dentures/partials?
Yes
No
Have you ever had injuries to teeth/jaw/jaw joints?
Yes
No
Do you have any fears/concerns about dental treatment?
Yes
No
Have you ever had any unusual experiences with dental care?
Is there anything else you would like to share with us?
Submit
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