Dental History

Name *

Email *

Phone

If so, when was your last dental visit?
Within the last 3 MonthsWithin the last 3-6 MonthsWithin the last 6-9 MonthsWithin the last 9-12 MonthsMore than 1 year agoMore than 2 year agoMore than 5 year agoNever

How would you rate your previous dental experience?
ExcellentGoodAveragePoor

What are your dental concerns?

If so, why have you avoided regular dental care?

If not, why are you unhappy with the appearance of your teeth?

How often do you brush?
Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day

How often do you floss?
Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day

How often do you use other aids?
Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day
water flosser, gum picks, gum stimulator, etc.

City

State / Province