About You Form – Onalaska and La Crosse Area Dentist | Valley Dental

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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

© 2020 Onalaska and La Crosse Area Dentist | Valley Dental.

Staff
Treatment
New Patients
Promotions
Financing
Blog
FAQ
Contact