The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.
Please share the following dates:
Please check any of the following problems that may apply to you:
Do you have or have had any of the following?
If you could change your smile, you would...
Do you have any of the following allergies?
You are solely responsible for payment of all fees incurred during treatment at completion of each appointment. If you have dental insurance, please remember that your insurance is a contract between you and the insurance company.
We do not accept personal cheques and cash. We do accept MasterCard, Visa, and Debit Card payments.
We encourage you to schedule appointments that are convenient for you to keep. If you must cancel or change an appointment we must have 2 full business days notice or a charge may be levied.