Dental History

Fill Out The Form Belows

Date(Required)

MM slash DD slash YYYY

Dentist Name(Required)

Why have you come to the dentist today?(Required)

Reason for change of provider?(Required)

Have you seen another dentist for your dental needs?(Required)

YES

NO

Please explain

How would you describe the condition of your teeth and gums?(Required)

Good

Fair

Bad

Are you currently in any pain or discomfort with your teeth or gums?(Required)

YES

NO

If yes, please explain :

How often do you brush?(Required)

How often do you floss?(Required)

Problems

Bad Breath

Grinding teeth

Sensitivity to hot/cold

Bleeding gums

Problems

Loose teeth

Sensitivity to sweets

Clicking or popping jaw

Broken fillings

Sores or growths in mouth?

Is there anything else we need to know about your dental history?

We are a team of experienced and compassionate dental professionals committed to providing high-quality care in a welcoming environment.

Follow Us

Important Links

Other Links

Newsletter Subscription

Email