Dental Survey

How can we help you schedule your first visit?

What is the reason for your appointment? *

Routine Cleaning

Check-Up

Consultation

Dental Pain

Cosmetic Dentistry

Other

When was your last dental visit?

Please provide the approximate date.

Are you currently experiencing any pain?

If yes, how would you rate the pain on a scale of 1 to 10, with 1 being the least and 10 being the most painful? *

1

2

3

4

5

6

7

8

9

10

How soon are you looking to schedule your appointment?

Please provide the preferred date and time that works best for you.

Is there anything you would like to share regarding your previous dental experience or dental history?

Please include any specific concerns or conditions that we should be aware of. *

Would you be interested in scheduling a complementary consultation?

Availability for consultations may vary, and we will reach out to you to confirm scheduling options. *

Yes

No

Please provide patient information accurately so we can successfully contact you.

First and Last Name *

Best Contact Number *

Email Address *

Do you have dental insurance?

Please provide your insurance provider name and details (if applicable).

Date of Birth

Dental Insurance Provider

We accept all PPO insurances and Medicare to help our patients. Additionally, we offer flexible payment arrangements, including 3rd party financing options, so you can get the care you need.

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