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

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.

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