1. Contact Name
2. Contact Email
3. Is this form for you or for someone you know? Myself Someone Else
4. Is this form for a child under 6? Yes No
5. Do you have current cavities/decay that needs to be treated/filled? Yes No
   If yes, please elaborate ...
6. Have you had a cavity in the last 3 years? Yes No
   If yes, please elaborate ...
7. Between brushings, do you get visible plaque on your teeth? Yes No
   If yes, please elaborate ...
8. Do you have a dry mouth? Yes No
   If yes, please elaborate ...
9. Are you taking any prescription medications? Yes No
   If yes, please elaborate ...
10. Do you snack frequently (1-3 times daily)? Yes No
    If yes, please elaborate ...
11. Do you drink acidic beverages (sodas, sports drinks, juices, etc)? Yes No
    If yes, please elaborate ...
12. Do you drink from a fluoridated water source? Yes No I don't know
13. Do you brush your teeth at least twice daily? Yes No
    What brand toothpaste do you use ...
14. Do you floss daily? Yes No
15. Do you use an oral rinse daily? Yes No
    What brand oral rinse do you use ...
16. Do you use any other types of oral care products (xylitol gum, sprays, etc.) Yes No
    If yes please elaborate on what you use ...
17. Do you have any other types of medical conditions or medical therapy such as Sjogren's syndrome, Acid Reflux, Bulimia, Radiation Therapy, etc?
    
18. Is there anything else you would like our dental professionals to know?
    

Please understand that your information is kept confidential and is only used to assist you in creating a customized treatment or prevention plan to help you be cavity free for life. Answering the questions as truthfully as possible will help ensure your treatment or prevention plan is as effective as possible.

Thank you and we look forward to serving you.