Start Your Stress-Free Smile Consultation Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Are you a current patient? *Yes, I am a current patientNo, I am looking for a new dentistFirst question!When was the last time you went to the dentist? *Within the last yearMore than a year agoDon’t worry – we don’t judge!When was the last time you went to the dentist? *Within the last yearMore than a year agoDon’t worry – we don’t judge!Your Name *FirstLastBefore we get too personal, let’s get your name. Since we are collecting health information, we will also need you to provide your last name. So, tell us: How often do you brush your teeth? *A few times a weekOnce a dayTwice a dayMore than twice a dayDaily oral hygiene is one of the biggest factors in oral health.Do you floss? *Yes, dailySometimesOnly if I have something stuck in my teethNeverRegular flossing helps prevent gum disease and tooth decay.How would you describe your gums? *Pink and firm to the touchPuffy and inflamedRed and recedingNow, let’s move on to your gums.Do you have any oral concerns?One or more of my teeth hurtMy teeth are sensitiveI have chipped or cracked teethI am missing teethI don’t like how my smile looksNope, I’m goodOther current often you Other oral concern:Email *By submitting this form, I agree to receive emails from Palm Court Family Dental.Submit Your Consultation
