Tel: (512)454-0414
info@smileaustin.com
2304 Hancock Dr Suite 1
Austin, TX 78756
Office Hours: Monday - Thursday: 7 AM to 5 PM
New Patients
For your convenience, please fill out the questionnaire below
Name:
Address:
Email Address :
Phone:
Date Of Birth:
Would like us to file your claims with your dental insurance?
YES
NO
Employer/Group Name:
Are you the employee?
YES
NO
If not, name of the employee:
Social security or ID#:
Insured Date of Birth:
I am interested in scheduling and appointment for the following:
Full exam/Preventatice Care Visit
When was your last cleaning?
AND/OR
I am having a toothache
I lost a filling
I broke a tooth
I think my wisdom teeth are coming in
Where is the tooth- upper or lower, front or back, right or left side of the mouth?
How long has it been bothering you?
Is there swelling?
YES
NO
Do you have sensitivity to hot, cold, or pressure, or do you have a constant ache?
YES
NO
What, if anything are you currently taking to relieve discomfort?
Would you like us to call your previous dentist to request your records?
YES
NO
Name and Phone number of previous dentist:
Comments:
