Registration Form
*- Indicates a required field

*Name
1) What prompted you to seek dental care at this time? *
2) Are you dissatisfied with your teeth in any way?
3) Are you dissatisfied with the way your teeth look? For example: Color, shape, spaces, etc
4) Do any of your fillings show when you smile?
5) If any of your silver fillings need replacement, would you prefer to have a natural, tooth-colored restoration?
6) Are your teeth sensitive to:
Heat?
Cold?
Sweets?
Biting Pressure?
7) Do your gums bleed when brushing?
8) Do you have an unpleasant taste or odor in your mouth?
9) Are you concerned about bad breath?
10) Do you want to learn to control dental disease and retain your teeth?
11) Has the fear of discomfort kept you from regular dental visits?
12) Are you deeply concerned about the finances required to return your mouth to excellent dental health?
13) When was your last dental appointment? *
- -
What did you have done?

14) How long since your last thorough
examination with full mouth x-rays?

15) Why did you leave your last dentist?

16) Is there anything else that we should know about you to take better care of you?

May we use photos of your teeth for educational or promotional purposes?
 

IMPORTANT: Please confirm the following to validate this registration:
By selecting this check box, you are confirming that you have filled out the above form to your best knowledge.


    

Patient Registration | Medical History | Dental History