New Patient Survey

Name

Please answer the following so we can prepare for your visit!

We know many patients feel some anxiety about their visit, and we want to help you discover the best experience in healthcare. Please check any of the following statements that describe you.

I have a strong gag reflex I am fearful about not being able to breathe properly I am fearful that I'll experience pain I prefer minimial conversation when I'm in the dental chair I enjoy ongoing conversation and explanations during my care I'm fearful I won't have any control over what's happening I don't feel fearful of dentistry

Please let us know if there's a beverage you'd enjoy before your appointment.

Water Coffee Tea Juice

What are you most interested in discussing with us?

To help us understand your dental history, please tell us about your last dental experience or your overall feeling about recent treatment.

Is there anything else you'd like us to know that would help us prepare for your visit?

New Patient Survey

Our team can’t wait to see you. Please share a little with us.