For Reducing Dental Fears @ Town & Country Dental of Oak Park

5-Star Comfortable Care at T&C Dental of Oak Park

We are available to help you with your fears, embarrassment and PTSD. Those concerns are actually quite common. We will treat you like family so we take great pride in helping you to feel relaxed and in control at your visits. Step 1 is to read our reviews. Step 2 is to meet Dr Wegner and our team. Step 3 is to begin slowly and when you feel ready. Complete this form to initiate a call back from our amazing team.

What is your fear level on a scale of 1 to 10?*

	1	2	3	4	5	6	7	8	9	10

1 is Enjoy Preventive Cleanings, 10 is Avoid Until Emergency Occurs

When was your last visit to a dentist?*

1-4 weeks1-12 monts1-2 years3-5 yearsMore than 5 years
Please describe your fear/PTSD and any past bad experiences:*
Overall Health of Your Teeth (select one):*

ExcellentGoodFairPoor
Overall Health of Gums (select one):*

ExcellentGoodFairPoor
Are you happy with your smile appearance?*

YesYes, but it could be improvedNo, I am self-conscious about my smile
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!
Contact Information:
Name*

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

Area CodePhone Number
Should be Empty:

5-Star Comfortable Care at T&C Dental of Oak Park