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THE HILLS DENTAL STUDIO

Thank you for submitting your

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submit your

Medical & Dental Health History

Help us customize your care!

First name*

Last name*

Address*

Birthday*

Month

Day

Year

Employer

School

How do you prefer to be contacted about appointments? *

Text

Call

Phone Number*

For your comfort or distraction from your procedure, would you like:

Anxiety prescription (before appointment)

Neck Pillow

Back Pillow

Chapstick

Blanket

Feel free to bring headphones to listen to your own music as well!

What are your dental health objectives? *

Pain-free

Bright, white smile

Keep your natural teeth

Fresh breath

Healthy gums

Straighter teeth

What, if anything, are you unsatisfied with regarding your teeth or smile?

To what level of health do you want us to make recommendations for you? *

1. Basic: Only fix something when it breaks (pain, broken teeth, abscess)

2. Informed: Be told about any current or potential issues so you can understand the problems and your options to treat or prevent them (overview)

3. Enhanced: Discuss how you can improve upon treatment and prevention to enhance your teeth’s appearance and health (whiten, straighten, cosmetics)

What do you do for fun?*

What motivated you to make this appointment (pain, checkup, etc.)?*

How did you hear about our office? (friend, Google, insurance site, etc.)*

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