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| WE WANT TO TAKE CARE OF YOUR CONCERN AND NEEDS FIRST |
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| Reason for today's visit |
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| Do you avoid brushing any part of your mouth |
Yes No |
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| Do your gums bleed when brushing |
Yes No |
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| Do you have persistent bad breath |
Yes No |
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| Are you gums red, swollen or tender |
Yes No |
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| Are you sensitive to sweets, hot/ cold, or biting pressure |
Yes No |
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| I want to know about longer lasting solutions that may cost more |
Yes No |
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| Are you dissatisfied with your teeth and their appearance |
Yes No |
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| Does dental treatment make you nervous |
Yes No |
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| I think my dental health is |
Excellent Good Fair Poor |
| If I could change my smile I would make my teeth |
Whiter Straighter Close spaces Repair chips |
| Other concerns/ needs of mine are |
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ABOUT US
