Patient Intake Questionnaire
What is your primary dental concern?
*
(ex.: tooth ache, broken tooth, cavity, problems with dental work, etc.)
Is there anything about your teeth that you wish was different?
Are you currently experiencing any other dental pain / problems?
*
Do you have specific goals for your teeth?
Please select any of our services that you may be interested in.
*
Comprehensive Diagnosis
Limited Diagnosis
Comprehensive Diagnosis & Treatment Planning
Limited Diagnosis & Treatment Planning
Dental X-ray Imaging
Evaluation of Existing and Current Dental X-rays
3-D CBCT Dental Imaging
Other
What factor(s) is/are most important to you in a dental office?
*
Location
Cost
Insurance Participation
Doctor / Staff
Office Size
Office Services
Appointment Availability
Treatment Speed
Office Decor
Specialist Procedures
Financing Options
Other
When was your last dental visit and what was done at that visit?
*
Do you currently have a general dental office that you see regularly, or will you need assistance in finding an office that is the right fit for you?
*
Are there specific questions or is there anything about your past dental experiences that you would like to share?
Name
*
First Name
Last Name
Save
Submit
Should be Empty: