Forms Aquaintence Form Health History Dental History Privacy Practices Privacy Acknowledgement Aquaintance Form Name, Address, Biographical and Contact Information Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Marital StatusSingleMarriedWidowedDivorcedSection BreakMy Mouth Is Very Comfortable Moderately Comfortable Uncomfortable I / I am think the appearance of my mouth is excellent satisfied with the appearance of my mouth dissatisfied with the appearance of my mouth I will do anything to keep my natural teeth want to keep my teeth, but have a certain budget of time and money I am willing to spend on them don't care whether I keep my teeth or not I have always done the best taht was recommended for my dental health have not done what dentists have recommended for my dental health rearely go, and don't care much about having my dental work completed I have put dentistry for myself and my family high on my priority list put dentistry for myself and my family on my priority list it's on my list, but hard to find I think my present state of dental health is excellent good poor I aspire to a mouth with excellent health good health poor health Section Break
