Hello, what is your first name?*

Nice to meet you, {name}. Welcome to Kansas Family Dental!

What would you like to focus on improving?*

Straighter teeth

Whiter teeth

Replace missing teeth

Repair damaged or chipped teeth

Reducing jaw pain or discomfort

Other

What other dental concerns would you like to focus on?*

What worries you most about your teeth alignment?*

Have you tried whitening products in the past?*

Yes

No, this is my first time!

Select the services or products you’ve tried.*

Select all that apply.

Over-the-counter

Take-home kits

Professional Services

Other

Unsure

What other services or products have you tried?*

How many teeth are you looking to replace?*

Single Tooth

Multiple Teeth

Full Replacement

Do you currently have dentures or partials?*

Yes

No

What type of damage are you experiencing?*

Select all that apply.

Cracked tooth

Chipped tooth

Worn down

Other

What other types of damage are you experiencing?*

Have you been diagnosed with TMJ or a related condition?*

Yes

No

Are you experiencing any additional symptoms?*

Select all that apply.

Discoloration or staining

Bleeding gums

Difficulty chewing

Sensitivity to hot or cold

Jaw pain or clicking

None

Other

What other symptoms are you experiencing?*

When was your last dental visit?*

Less than 6 months ago

6-12 months ago

1-2 years ago

Over 2 years ago

Never/Unsure

Have you had cosmetic dental work before?*

Yes

No

What cosmetic dental work have you had?*

Patient Information

Enter your name and email address so we can get in touch with you and guide you through the next steps in your smile planning process.

First Name*

Last Name*

Phone Number*

e.g. (555) 555-5555

Email Address*

e.g. email@domain.com

Comments

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Nice to meet you, {name}. Welcome to Kansas Family Dental!

Patient Information

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