57 Street Rd. Suite M | Southampton, PA 18966
Whom may we thank for referring you to our office:
Do your gums bleed while brushing or flossing? Yes No
Do you have frequent headaches? Yes No
Are your teeth sensitive to hot or cold liquids/food? Yes No
Do you clench or grind your teeth? Yes No
Do you feel pain in any of your teeth? Yes No
Have you ever had any prolonged bleeding following extractions? Yes No
Do you have any sores or lumps in/near your mouth? Yes No
Do you wear dentures/partials? Yes No
Do you have a concern with snoring? Yes No
Have you ever experienced any of the following problems in your jaw?
Clicking Pain (joint, ear, side of face)
Difficulty opening or closing Difficulty in chewing
Do you like your smile? Yes No
If not, what would you like to change?
Have you ever had orthodontic treatment? Yes No
Have your teeth shifted since? Yes No
Signature of Patient, Parent or Guardian:
Signature of patient/responsible party certifies that you have read and completed the above information to the best of my knowledge. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.