• Dental History

  • Primary reason for Dental Appointment
  • Do you have a specific dental problem?
  • Are your teeth sensitive to:
  • Are you in pain?
  • How would you describe your present dental health?
  • Do you think you have active decay/cavities?
  • Do you think you have gum disease?
  • Do your gums bleed?
  • Do you have bad breath?
  • Have you ever been taught to control dental disease?
  • Clicking, popping, or discomfort in the Jaw joint?
  • Do you clench or grind your teeth?
  • TMJ(Jaw Point) Therapy?
  • Do you have any sores or growths in your mouth?
  • Have you ever had gum surgery?
  • Braces?

  • To make your visit as comfortable as possible. I'd like to ask you a few questions. In our office, we believe that the person attached to the teeth is important, if not more important than the teeth. The more we know about your needs, desires and concerns, the more we can provide you with what you want.

  • Are you pleased with the appearance of your teeth?
  • Would you like information on teeth whitening?
  • Have your past dental experiences always been positive?
  • Do you have any fear of dental treatment?
  • How much dental work do you feel that you need?

  • SUGAR LAND DENTAL PAYMENT POLICY

  • Sugar Land Dental requires payment for services at the time of service, or when treatment is rendered. We accept many types of payment including cash, checks and credit cards. We have also contracted with a national credit agency in which you can apply for third party financing for services over $500.00.

    Sugar Land Dental will file, on your behalf, your primary dental insurance coverage for services performed. These claims are filed as a courtesy to our patients and do not ensure insurance coverage. In the event insurance claims are denied or not paid in full, the patient will be responsible for payment of services.

    Please sign below to indicate your understanding of Sugar Land Dental's payment policy. Additionally, please feel free to contact us if you have any questions concerning our payment policy. 

    ANY APPOINTMENT CHANGE OF LESS THAN 48 BUSINESS HOURS NOTICE WILL BE SUBJECT TO A CANCELLATION FEE AND/OR PREPAYMENT TO RESERVE FUTURE APPOINTMENTS.

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