New Patient Interview

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

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

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.)