First Name*

Last Name*

Email Address*

Phone Number*

How do you feel about dental treatment?

Have you seen a dentist before?

If so, when was your last dental visit?

How would you rate your previous dental experience?

What are your dental concerns?

Have you avoided regular dental care?

If so, why have you avoided regular dental care?

Are you happy with the appearance of your teeth?

If so, why have you avoided regular dental care?

How often do you brush?

How often do you floss?

How often do you use other aids?

Would you like your teeth to be whiter?

Would you like your teeth to be straighter?

Do you have, or have you ever had any of the following dental conditions? Please check all that apply.*

Previous dentist or dental office

Name of previous dentist or dental office

City

State

State / Province

Signature*

Full Name

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Dental History