Your dental background

First name

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Last name

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When was your last dental visit?

Within 6 months 6–12 months ago 1–3 years ago 3+ years ago Honestly can't remember

Previous dental office (optional)

If you'd like us to request your records, we'll help with the transfer.

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Would you like help transferring your records and x-rays?

Yes please No / not applicable

How's your mouth right now?

Any current concerns?

Tell us about the pain — where, when, how long?

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How often do you floss?

Daily A few times a week Occasionally Flossing and I are not acquainted

How do you feel about dental visits?

Relaxed Slightly nervous Anxious Very anxious / phobic

Thanks for telling us — it changes how we'll plan your visits. You may like our sedation options, including a 5-minute nitrous trial.

What do you want from your smile?

Check anything you're interested in

Just keep everything healthy Whiter teeth Straighter teeth Replace missing teeth Fix chipped/worn teeth A full smile makeover Help with dental anxiety Better checkup habits for my kids

In your own words — anything you've always wanted to ask a dentist?

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Dental History

Your dental background

How's your mouth right now?

What do you want from your smile?

Thank You — We've Got It!