Hawthorne Dental Intake Form
Please Note: The information you provide will only be shared directly with the dentist to help schedule your consultation.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code
*
Who needs to be seen?
*
Self
Kid(s)
Self + Kids
Spouse
Self + Spouse
Family
Scheduling for dependent (Foster, Elderly etc.)
How would you like to improve the appearance of your smile?
*
Resolve crowding
Close my spaces
Improve the color of my teeth
Fix my bite
Fix chip
All the above
What would you like to know more about?
*
Traditional braces
Invisalign
Impants
Veneers
Bleaching
Orthodontics
If you have missing teeth, how would you like to replace them?
*
Implants (Fixed)
Partial/Dentures (Removable)
Doesn't apply
Do you have any of the options below?
*
Bleeding gums
Tatar/Palque/calculation/buildup
bad breath
None of the above
Do you have a toothache?
*
Yes
No
Please specify where below.
*
Is there anything else you would like to share?
*
Submit
Should be Empty: