Oral problem intake form

Oral Care Problems.

Fill out this HIPPA compliant form and our oral health experts can find the best dental products for your oral care needs and provide information on how to use these products!
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Age*
Main issues with your oral care and teeth*

Dark yellow teethBleeding gumsProne to cavitiesTeeth grinding/night grindingCrowded, crooked teeth, and bite issuesTooth pain to cold, hot, pressureNo problems my teeth are greatCrowns or bridge workMissing teethExisting dental implantsTreatment with braces or aligners in the pastCosmetic issues with my teeth i.e. chipped, broken teethExisting root canal treatment
Oral problem risk assessment questions*

High dietary in-take of sugary foods i.e. sodas or candy on a daily basisTeeth or gum problems in relatives, Mother or Father with know oral issuesRegularly see a dentist for cleaning and exam every 4-6 monthsHistory of cancerHistory of eating disordersTaking medications that decrease salivaTeeth missing due to cavities in the last 3 yearsVisible build up on your teeth, or bleeding gumsWorn teethLoss of gum at the base of teethFood getting stuck in teeth and or around gumsSevere dry mouthSnoring and or night mouth breathingCosmetic concerns with smile and teeth, don't like your smileNo problems my teeth look and feel good
Are you currently taking any medication?*

YesNo
Are you interested in Products that Protect against Covid 19?*

YesNoMaybe
Do you have any medication allergies?*

YesNoNot Sure
What is your Gender?*

MaleFemale
Do you use or do you have history of using tobacco?*
Do you use or do you have history of using illegal drugs?*
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
What are you using for your oral care now? Please provide short description of dental products and how you use them.
Signature (I understand my HIPPA rights as stated on our site, this is not intended to replace a in office dental visit, but to help with products selection for your needs.)*

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Should be Empty:

Oral Care Problems.