Liz M.

Are you already an established patient with our office?

Yes

How did you find out about our practice?

Who referred you to us? *

What is the reason you need a dental visit?

Checkup and Cleaning

Specific Treatment

Urgent Issue

Please describe the urgent issue you are experiencing and would like the doctor to know about.

Are you experiencing pain? Do you have a cracked or broken tooth?

How long has it been since you last visited the dentist?

Less than 1 year

1-2 years

More than 2 years

I have never visited a dentist

Do you feel nervous about visiting the dentist?

Preferred time for an appointment.

Morning (9 am - 12 pm)

Noon (12 pm - 2 pm)

Afternoon (2 pm - 5 pm)

Evening (after 5 pm)

How soon do you require an appointment?

As soon as possible

Within 1 week

Within 2 weeks

In more than 2 weeks

Do you have dental insurance?

Yes

Who is your dental insurance provider?

Name (first and last) *

Email Address *

Phone Number *

What is your preferred method of contact?

Phone

Text

When would be the best time for our staff to reach out to you and confirm the appointment?

Please select all that apply.

Comments

If you are human, leave this field blank.

Liz M., Dental Assistant