New PatientExisting Patient
Appointment Type (select all that apply):Check UpCleaningUrgent Issue/In PainSpecific Treatment
How long has it been since you last visited the dentist?<1 Year1-2 Years2+ YearsI've Never Visited
Do you feel nervous about visiting the dentist?Not at allA littleModeratelyVeryExtremely
Preferred Time*MorningAfternoonEvening
Do you have Dental Insurance?YesNo
How would you prefer to be contacted?Phone CallEmail
How did you find out about our practice?InternetFlyer/MailerPoster/Sign/BillboardReferral/Word-of-MouthOther
