New Patient

Application Form

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1. What is your primary issue? *

Bleeding gums

Chipped or broken teeth

Sensitive teeth

Loose or missing teeth

Bad breath

Cosmetic concerns (whitening, alignment, etc.)

Other

2. How long have you been dealing with this? *

Less than 1 month
1-3 months
3-6 months
6+ months
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3. What have you tried so far? *

No, I haven’t had any prior treatment

Yes, I have had a filling or restoration

Yes, I have had an extraction or surgery

Yes, I have had orthodontic treatment (braces, Invisalign, etc.)

Yes, I have had orthodontic treatment (braces, Invisalign, etc.) Yes, other:

Yes, other.

4. Do you have any existing medical conditions or are you taking any medications that might affect your dental care? *

Personal & Contact Information

Full Name *

Email *

Phone *

What time of day works best for us to reach you?

Morning
Afternoon
Evening
Anytime
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