Thank you for choosing our office for your dental needs. We strive to make your visit a comfortable and pleasant
experience. We place a high emphasis on helping you determine your present and future dental needs. We want to
know what things are most important to you and your dental health as we will be discussing these issues with you
during your visit. Please check what best expresses how you feel about the following questions.

Are you having any areas of concern?


Tell us, in your opinion, what you think is the present state of the health of your mouth.
Poor Average Good Excellent

What do you already know about our office and what are your expectations?


How healthy do you want us to get your mouth?
Don't care Average The best it can be

Should you need treatment, at what point should we address it?
When my tooth hurts or breaks When something is worsening When something isn't its best

What quality of dentistry do you want us to recommend?
Just patch it Average Ideal/Best

We have the ability to look at your mouth from 3 different perspectives. Which would you like us to use for you?
As a general dentist As a functional dentist As a cosmetic dentist

How do you feel about the overall appearance of your smile?
Poor Average Good Excellent

How do you feel about the shade of your teeth?
Poor Average Good Excellent

How do you feel about the shape of your teeth?
Poor Average Good Excellent

In your opinion, what characteristics make a trustworthy dentist?


Has fear ever been an issue for you in a dental office?
Yes No

What caused you to leave your last dental office?


Has time ever been a factor in getting your dental work done?
Yes No

Has the cost of dental treatment ever been a concern for you?
Yes No

Is there any additional information you would like us to know? If so, please explain.




First Name: Last Name: Appointment Date: