Dental & Orthodontic Intake Form

Please complete this form to help us provide you with the best possible dental care. Your information is secure and confidential.

Personal Information

Full Name *

Date of Birth *

Primary Dental Concern *

Type of Treatment Seeking *

Pain Level (0-10)

Last Dental Visit

Do You Have Recent X-rays?

Yes No

Any Missing Teeth?

Yes No

Dental Insurance Provider

Budget Range for Treatment

Do You Experience Dental Anxiety?

No anxiety Mild anxiety Moderate anxiety Severe anxiety

Preferred Days/Times for Appointments

Email Address *

Phone Number *

Your information is secure and will only be used for dental care purposes