IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand.
PLEASE FILL IN THE ENTIRE FORM
Have you ever experienced any of the following problems your jaw:
To the best of my knowledge, the above information is correct: