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16Harmony Family Dental
Harmony Family Dental
10103 N. DIVISION SUITE 201
SPOKANE, WA 99218
509-467-1562
Miscellaneous
Has fear ever been an issue for you in a dental office?
Yes
No
Has time ever been a factor in getting your dental work done?
Yes
No
Has the cost of dental treatment been a concern for you?
Yes
No
If yes, how can we help?
Tell us about your good dental experiences/visits:
Tell us about your bad dental experiences/fears:
What do you like most about your teeth/smile?
Is there anything you don't like about your teeth/smile?
Is there anything you'd like to change about your teeth/smile?
What are your long-term dental goals? How would you like your teeth to feel and look?
What are your short-term dental goals?
Do you have any upcoming event or circumstances (such as weddings, major surgeries, etc.) we should/need to know about? If
yes, what and when?
Yes
No
Is there anything else you feel we should know?
Medical History
How is your general health?
Good
Fair
Poor
Are you currently under medical treatment? If yes, what for?
Yes
No
Do you require antibiotic pre-medication for your dental work? If yes, what for?
Yes
No
Physician's Name:
Phone:
Last Visit:
-
-
/
01
2027
Address:
City:
State: ZIP Code:
02
2026
03
2025
AL
Do we have permission to contact your doctor regarding your care?
04
2024
Yes
No
AR
05
2023
AZ
06
2022
CA
Page 8/16
07
2021
CO
08
2020
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Parent category: Medical