Please fill out form below and click the submit button when you are finished Getting To Know You Name * Date * Phone Number * Email * Please describe the reason for your consolation today: * How long has this been going on and what other events apply to today's visit? * Why have you decided to deal with this now? * Have you consulted with any other dentist about this? * Yes No If yes what was discussed or done? * When was your last dental checkup * Who is your regular or previous dentist? * Have you noticed or has any dentist or hygienist ever said to you (Check all that apply): Have gum disease (Gingivitis) Grind your teeth Clicking or popping jaw Jaw Pain or Tenderness Pain around the ear Lip or cheek biting Loose or broken teeth or fillings Food collection between teeth Sores, blisters or growths Bad Breath Do you have sensitivity to (Check all that apply) Cold Heat Sweets When biting or chewing Would you like to know your options to (Check all that apply) Improve your smile Look younger Keep your teeth What are your priorities and what would you like to see down now? * How did you hear about us? * If you are human, leave this field blank.