Dental History

Dental HistoryDr. Sabbahi2019-06-27T20:39:49+00:00

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*
Date Format: MM slash DD slash YYYY