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!
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Main issues with your oral care and teeth
Dark yellow teeth
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
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
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?
Are you interested in Products that Protect against Covid 19?
Do you have any medication allergies?
What is your Gender?
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?
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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