What is the reason for your visit?
When was your last dental visit?
How often do you have dental cleanings?
Have you ever been told to take a pre-medication prior to dental treatment?
How often do you brush your teeth?
How often do you floss your teeth?
What other dental aids do you use?
Have you ever had:
If "yes", please share what type of dental appliance.
Have you experienced:
Are you satisfied with your teeth's appearance?
Do you feel nervous about having dental treatment?
Is there anything else about having dental treatment that you would like us to know?
Date Of Birth
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