First Name *

Last Name

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

I agree

How often do you brush your teeth? *

Twice or more daily

Once a day

A few times a week

Rarely or never

How often do you floss? *

Daily

A few times a week

Occasionally

Never

Do you use fluoride-based products? *

No, I avoid fluoride

Occasionally

Yes, regularly

Not sure

How would you describe your diet? *

Clean, organic, low in processed foods

Balanced, but some processed foods

High in sugar, processed foods, acidic beverages

I eat whatever is convenient

Do you experience gum bleeding? *

No, never

Occasionally

Yes, frequently

My gums bleed very easily

How often do you visit the dentist? *

Every 6 months or more

Once a year

Every few years

Haven’t been in a long time

Do you experience frequent tooth sensitivity? *

No, never

Occasionally

Yes, but it’s mild

Yes, and it’s severe

Do you grind or clench your teeth? *

No, never

Yes, and I wear a nightguard

Occasionally

Yes, but no nightguard

Have you had any root canals? *

No

Yes, but only 1

Yes, but removed

Yes, 2 or more

Do you have mercury (silver) fillings? *

No, never had them

Yes, but safely removed

Yes, but removed without safety

Yes, I still have them

If you currently have silver fillings, how many? *

None

1-2

3-5

6 or more

How long have you had silver fillings? *

N/A

Less than 5 years

5-10 years

More than 10 years

Do you have any metal crowns, bridges, or implants? *

No

Yes, metal crown

Yes, metal bridge

Yes, metal implant

Do you experience frequent headaches, jaw pain, or TMJ? *

No

Occasionally

Yes, frequently

Yes, diagnosed with TMJ disorder

Have you had gum disease or periodontal treatments? *

No, never

Yes, mild gingivitis

Yes, deep cleanings

Yes, diagnosed with periodontal disease

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