Consultation Form
Patient First Name
Patient Last Name
Patient Birth Date
What are your pronouns?
He
She
They
Other
Other
Tell us about yourself
How frequently do you go to the dentist?
Tell us about your experiences at the dentist?
What do you like or dislike about your smile?
How often do you brush and floss your teeth?
What motivated you to make an appointment with us?
What would you like to know about the practice, dentist and hygienist?
What are your beliefs and feelings about going to the dentist?
If you have any current dental problems, how do they affect you?
What are your dental health goals? (Check all that apply)
To handle only my most pressing needs
To be pain free
To improve my facial appearance
To retain my teeth for the rest of my life
To have a bright, white smile
To have straight teeth
To have fresh breath
To have healthy gums
What are your dental treatment goals? (Check all that apply)
Handle any problems the right way the first time
Know everything that is going on in my mouth regardless of the severity
To complete my treatment faster by having fewer, longer appointments
To complete my treatment by having more, shorter appointments
What office services matter most to you? (Check all that apply)
Flexible appointment scheduling
Appointment reminder calls/ texts/ emails
Punctual start and finish to my appointment
A warm, moist towel after each visit
Favorite magazine in the waiting room
A follow-up phone call after each visit
Title to Favorite Magazine
On a scale of 1-10 (10 being the highest), how committed are you to having all of your dental problems resolved?
What concerns or challenges do you face in achieving optimal dental health?
Form Completion
Patient, Parent or Legal Guardian Signature
Clear
Clear
Please sign the document
Date
If Patient is a Minor
Printed Name
Relationship to Patient
Online Signature
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Draw your signature inside the box
Clear
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