First Name *

Last Name *

Name Of Contact (If Different From Patient)

Date Of Birth *

Phone *

Email *

Dentist Name *

Does the Patient Have Medicaid Coverage For Dental Insurance? *

Yes

(Patients who do will have a Medicaid ID number listed on their insurance card).

In Your Own Words, What Is Your Main Concern With Your Smile? What Would You Like To See Improved?

When Was The Last Time You Had A Cleaning With A General Dentist? *

Do You Have Any Active Cavities? Do You Have Any History Of Gum/Bone Disease Such As Gingivitis Or Periodontitis? *

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