Nice to meet you Thank you for your interest in our office. We feel strongly that a patient’s philosophy about their own health should match the philosophy of their dental practice. The following survey can help determine whether we are a good fit for each other Name * First Name Last Name Best Phone Number to Reach You * (###) ### #### Email where we can send correspondence * Dental Insurance Please list all dental coverage How did you hear about our office? * Have you ever been to a Periodontist or been told you have periodontal disease? * In the last 2 years how often have you gotten your teeth cleaned? * --choose one-- Every 3 months Every 4 months Every 6 months It's been a while Tell us about any current or past TMJ problems Do you wear a night guard or has anyone recommended something for grinding your teeth? We start all new patients with a full set of x-rays. Do you feel you have a recent set of x-rays you’d like us to review prior to your first visit? * Please rate how you feel the following statements apply to you. * My oral health is a priority to me Strongly Disagree Disagree Neutral Agree Strongly Agree Cost is the most important factor in my dental decisions Strongly Disagree Disagree Neutral Agree Strongly Agree Routine preventative x-rays and examinations are important to help prevent undetected problems in my mouth Strongly Disagree Disagree Neutral Agree Strongly Agree I like having my teeth cleaned Strongly Disagree Disagree Neutral Agree Strongly Agree I am looking for more information about the following treatments Invisalign Cosmetic Veneers or Crowns TMJ Treatment Implants Anything else you would like us to know Your form has been submitted.If we have availability for new patients we will reach out to you by the contact information provided in the form.If you have urgent dental needs, please contact a separate dental or medical provider promptly as we do not have emergency dental appointments for individuals who are already patients at our office.
