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

Dark yellow teeth Bleeding gums Prone to cavities Teeth grinding/night grinding Crowded, crooked teeth, and bite issues Tooth pain to cold, hot, pressure No problems my teeth are great Crowns or bridge work Missing teeth Existing dental implants Treatment with braces or aligners in the past Cosmetic issues with my teeth i.e. chipped, broken teeth Existing root canal treatment
Oral problem risk assessment questions *

High dietary in-take of sugary foods i.e. sodas or candy on a daily basis Teeth or gum problems in relatives, Mother or Father with know oral issues Regularly see a dentist for cleaning and exam every 4-6 months History of cancer History of eating disorders Taking medications that decrease saliva Teeth missing due to cavities in the last 3 years Visible build up on your teeth, or bleeding gums Worn teeth Loss of gum at the base of teeth Food getting stuck in teeth and or around gums Severe dry mouth Snoring and or night mouth breathing Cosmetic concerns with smile and teeth, don't like your smile No problems my teeth look and feel good
Are you currently taking any medication? *

Yes No
Are you interested in Products that Protect against Covid 19? *

Yes No Maybe
Do you have any medication allergies? *

Yes No Not Sure
What is your Gender? *

Male Female
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? *

Daily Weekly Monthly Occasionally Never
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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Oral Care Problems.