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Welcome
The Valley Dental Team
New Patients
About You Form
Patient Medical History
Patient Registration Form
Office Financial Policy
Patient Consent Form
Financing
Contact Us
To better serve your dental needs, please tell us about you and your smile.
Patient Name
*
How did you hear about Valley Dental?
*
When were you last seen by a dentist?
*
Why did you leave your previous dentist?
*
What are some of your hobbies or special interests?
*
Are you currently experiencing dental pain or sensitivity?
*
Yes
No
If yes, how long?
How often do you have your teeth cleaned?
Do your gums bleed while brushing or flossing?
*
Yes
No
How important is it that you retain your natural teeth?
Do you like the appearance of your teeth?
*
Yes
No
Do you like the appearance of your smile?
*
Yes
No
Do you like the appearance of your teeth color?
*
Yes
No
Do you like the appearance of your teeth shape?
*
Yes
No
Do you have any concerns about halitosis (bad breath)?
*
Yes
No
Would you like a staff member to discuss treatment for halitosis?
*
Yes
No
Welcome
The Valley Dental Team
New Patients
About You Form
Patient Medical History
Patient Registration Form
Office Financial Policy
Patient Consent Form
Financing
Contact Us
Valley Dental
1637 Main St
Onalaska, WI 54650
Phone:
(608) 781-3999
