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New Patient Screening Form
First Name
Last Name
Date Of Birth
How did you hear about us?
What is the main reason you scheduled with us?
How long has it been since your last visit to a dentist?
How happy are you with your smile right now?
Would you like photos to see your teeth and smile when we discuss your treatment plan?
Do you currently have Periodontal Disease?
Do you currently snore when sleeping?
Do you currently use any of the following? (check all that apply)
Have you currently or previously experience any of the following? (check all that apply)
Have you experienced or had any of the following? (Check all that apply)
Do you currently have a mouth guard (occlusal guard)?
Have you noticed and unusual lumps in your mouth or around your head/neck?
Are you interested in more information about any of the following? (check all that apply)
Are you currently missing any teeth that you would like replaced?
Are you interested in any of the following? (check all that apply)
Would you like more information about any of the following? (check all that apply)
Patient/Legal Guardian Signature
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