Dental History

Please select any of the following problems that apply to you:*

Where?

If I could change my smile, I would:*

Where would you rate your current dental health?*

On a scale of 1 - 10, with 10 being the highest rating:

Where do you want your dental health to be?*

On a scale of 1 - 10, with 10 being the highest rating:

Why did you leave your last dentist?*

Patient Name:*

First Last

Patient Signature*

Date*