Patient Survey

Please fill out our Patient Survey form to speed up your intake process when coming in for your first visit. If you can’t finish the form in one sitting, you can scroll to the bottom of the page and Save and Continue for later. You can also DOWNLOAD the form here and email it back in at your convenience.

Name*
First Last
Date of Birth*
How did you hear about us?
How long has it been since you have seen a dentist?
Are you:
- In pain
- Swollen
- on Pain medications
Have you ever taken antibiotic premedication before a dental visit?*
- Yes
- No
Do you have an Artificial Heart Valve?*
- Yes
- No
Do you have Prosthetic Joint Replacement?*
- Yes
- No
Are you on Blood Thinners/Anti-Coagulant*
- Yes
- No
Is there anything you would like to tell us about your previous dental experience?
Are there any changes you’d like to see to your smile?
Are you interested in more information on the following? Please check all that apply.
- Clear Braces
- Whitening
- Dentures
- Partials
- Veneers
- Crowns
- Athletic Guards
- Tooth-Colored Fillings
- Replace Metal Fillings
- Night Guard
- Bridge
- Implants
- Periodontal Treatment
- Sensitivity Treatment
YOUR REQUIRED SIGNATURE HERE IS FOR AUTHORIZATION FOR TREATMENT
Date
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Take Advantage of our Specials!

Business hours:
Monday: 8am-5pm
Tuesday: 7:30am-5pm
Wednesday: 8am-7pm
Thursday: 8am-5pm
Friday: 7:30am-3pm

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Any questions? Get in touch!

Name
Email
Message
Comments
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