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New Client Questionnaire

 

 

Your individuality is very important to us.  Please answer the following questions so that we may better serve you.

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Please enter the spam-filter code (see above):
What is your primary goal in seeking our services?
Are you currently having areas of concern with your mouth or teeth?
Is the present state of your mouth? Good
Slightly Neglected
Neglected
What quality of dentistry are you searching for? Average
The best it can be
Would you like for us to consult with you for? Cosmetic dentistry
General dentistry
Both
Would you like to change your smile? Yes
No
If yes, please explain:
How long have you wanted to change your smile? Since I was a child
Since I was a teenager
Since I was a young adult
Just recently
How have your previous experiences been with dentists? Mostly good
Mostly bad
How did you find us?
Why did you choose us?
How may we earn your trust?
Do you currently have a dentist? Yes
No
Have you had full mouth x-rays in the past 12 months? Yes
No
Are you fearful of dental treatment? Yes
No
Is time a factor in getting dental treatment? Yes
No
Is the cost of dental treatment a concern for you? Yes
No
Are there currently other financial commitments that will delay treatment? Yes
No
Do you want to discuss financing options? Yes
No
If so, how would you rate your credit? Excellent
Good
Fair
Poor
 
Will you need to consult a family member regarding your treatment and the related costs? Yes
No
Is there anything else you would like to tell us or ask about?
Mr./Ms./Mrs.
Please enter your full name:
Please enter your email address:
Home Phone
Work Phone
Mobile Phone

© Copyright 2008 Dustin Nelson DDS, Inc.  All rights reserved.

 

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