About You Form | Valley Dental

1.608.781.3999
1637 Main St, Onalaska, WI 54650
info@valleydental.us

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About You

About You Form

To better serve your dental needs, please tell us about you and your smile.

Patient Name*
First Last
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
SECURITY QUESTION: Please answer the following 2+2 =*
Comments
This field is for validation purposes and should be left unchanged.

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Business Hours

Monday	7:00AM - 5:00PM
Tuesday	7:00AM - 5:00PM
Wednesday	7:00AM - 5:00PM
Thursday	7:00AM - 5:00PM
Friday	7:00AM - 1:00PM
Saturday	CLOSED
Sunday	CLOSED

Office Info

1.608.781.3999 1637 Main St, Onalaska, WI 54650 info@valleydental.us

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