Dental History
Please answer the following items as completely as possible. Please complete all sections that apply. Click the 'Submit' button at the bottom of the form when you are finished. Thank you!

Dental History

 
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How often do you...

 
What was the date of your last...

 
Personal History

 
Smile Characteristics

 
Tooth Structure

 
Gum and Bone

 
Bite and Jaw Joint

 
Is there anything else about having dental treatment
that you would like to let us know?

 
By submitting this form, I consent to the doctor's exam
and necessary diagnostics for treatment, including x-rays.

 
Submit Form

 
Submit Completed Form