APPLY TO BE A PATIENT

APPLY TO BE A PATIENT
Please take your time completing this 3-part application. This process includes:
- Health History & Patient Questionnaire: Complete our short health history form and share more about your dental journey. This helps us understand your goals, lifestyle, and health practices.
- Dental Imagery/Previous Records: Give us an idea of your current oral health! Using a smartphone, a friend, and good lighting, capture the following images (examples and descriptions provided). Additionally, Dr. Kriegel requires your most current panoramic x-ray (available from your current dental office). This image must be uploaded to complete the application. Please reach out to our office if you have any questions.
- Bonus Video: Record a video telling us why you want to be a patient at Vios.
Your Basic Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Contact Number*
Email Address*
example@example.com
Preferred Contact Method:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about us?*

Your Medical and Dental Information
Are you currently working with any alternative healthcare providers (ie chiropractors, acupuncturists, naturopaths, functional medicine doctors, etc.)?*

YesNo
If yes, please explain.
Are you being treated for any chronic diseases?*

YesNo
If yes, please explain.
Have you experienced any issues with snoring, waking up feeling tired, or pauses in your breathing during sleep (sleep apnea)?*

YesNo
Are you taking any prescription, over-the-counter medicines, or supplements? Upload a photo or list below.

You can upload the following file types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, HEIC, mov
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Please list any medications and/or supplements.

Your Health Goals
Why are you interested in health based dentistry with Dr. Kriegel?*
What additional health goals are you focusing on, beyond oral health?*
If you are to sign on for treatment with Dr. Kriegel, what are your biggest concerns or fears about your current dental situation?*

Your Dental Images

Please see below for the images required. Click the image below to watch the how to video: https://www.youtube.com/watch?v=iBIS6VV3S_8
1. FULL FACE - A full face shot with natural smile
2. NATURAL SMILE AT REST - A natural expression at rest
3. BIG SMILE - A “cheesy” smile
4. OPEN SMILE - A retracted smile, teeth slightly apart
5. RETRACTED RIGHT SIDE - A retracted right side profile
6. RETRACTED LEFT SIDE - A retracted left side profile
7. UPPER ARCH - A retracted upper arch
8. LOWER ARCH - A retracted lower arch
Please upload your images here. *

Please upload only the following file formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, HEIC, mov
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When in doubt, capture the image further away than too close as the focus tends to blur when too close. All images should be taken with help for ease and quality.

**Bonus Video
By now, you should know a lot about us and what we do. Now, we want to know a little more about you! If you feel comfortable and are able, please upload a short video about why becoming a patient of Dr. Kriegel is important to you.
File Upload

Please upload only the following file formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, HEIC, mov
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Should be Empty:

Your Basic Information