Dental Assessment Form

Please identify and describe yourself:

First Name
Last Name
Date of Birth
Sex	Male Female

Street Address

City   State  

Zip Telephone

Email Address

Emergency Contact

Insurance Provider

Insurance Policy/Group #

Dental work you wish performed (by tooth number as per Dental Identification Chart)

Please list all missing teeth (by tooth number as per Dental Identification Chart)

Have you ever tested positive for HIV?  Yes  No

Any medical problems or special needs?

Travel Arrangements and Room Accommodations            

List the closest bus station

List the closest train station

List the closest airport

What kind of Room do you prefer? Single     Shared 

Please Note:

you will receive an estimate of costs with options to make this trip meet your needs.

A Representative will contact you to discuss options as well as travel arrangements.

Thank You 

Smiles For Less