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Welcome: USA Map Dentist: Texas Dentist: Collage Station Dentist Request Form:

Do You Sell Services or Products

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Find the Best Dentist In Your City Just Fill The FREE Form Below.

Find the Best Qualified Dentists in College Station and Have Them Bid on Your Health Needs

Find the Best Qualified Dentists In College Station Texas, by Using Our Pre-Qualified Prescreened Health & Fitness Business Directory.

Let The Best Health Care Professionals Bid on Your Health Needs.

Find the Best Dentist In Your City Just Fill The FREE Form Below.

What Type of services do You need from a Dentist?

Date of most recent dental examination:
How often do you brush your teeth?
How often do you floss?



YES	NO	DENTAL HISTORY

		Teeth sensitive to hot or cold; teeth throb or ache?
		Started teething very early or late?
		Bleeding gums, bad breath, mouth odor?
		Periodontal "Gum Problems"?
		"Gum Boils", frequent canker sores, cold sores?
		Are you taking any forms of fluoride?
		Thumb, finger, sucking habit?
		Abnormal swallowing habit (tongue thrusting)?
		History of speech problems?
		Any pain in jaw or ringing in the ears?
		Do you experience any pain or soreness in the muscles of the face, or around the ears?
		Difficulty encountered in chewing or jaw opening?
		Any teeth irritating cheek, lip, tongue, palate?
		Any wisdom tooth problems?
		Have you ever had a prior orthodontic examination or treatment?
		Have You ever had periodontal (gum) treatment?
		Would You object to wearing orthodontic appliances (braces) should they be indicated?

First Name

Phone # to Contact you

Email Address:

State

Zip Code

City


Best Time to be Contacted