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About
Dr. Sharbash
Services
Patients
Payment
Blogs
Contact
Appointment Request
Menu
About
Dr. Sharbash
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Appointment Request
About
Dr. Sharbash
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Dental History
Dental History
First Name
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Last Name
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Email Address
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Phone Number
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How do you feel about dental treatment?
Relaxed
A little uneasy
Tense
Anxious
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Have you seen a dentist before?
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How would you rate your previous dental experience?
What are your dental concerns?
Have you avoided regular dental care?
If so, why have you avoided regular dental care?
Are you happy with the appearance of your teeth?
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If not, why are you unhappy with the appearance of your teeth?
How often do you brush?
How often do you floss?
Would you like your teeth to be whiter?
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Would you like your teeth to be straighter?
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Do you have, or have you ever had any of the following dental conditions? Please check all that apply.
Aching or sensitive teeth
Areas of food traps
Broken filling
Cavities
Cold sores
Dry mouth
Facial surgery
Growths or lesions in your mouth
Gum treatments
Jaw clenching
Night guard
Orthodontic treatment
Swelling or lumps in mouth
Teeth grinding
None of the above
Active decay of teeth or gums
Bad breath
Broken or missing teeth
Clicking or popping jaw
Difficulty opening wide
Aesthetic concerns with teeth
Gag easily
Gum infection / disease
Jaw pain or tiredness
Loose teeth
Oral surgery
Sensitive or bleeding gums
Swollen glands
Unfavorable dental experience
Name of previous dentist or dental office
State / Province
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1441 Avocado Ave, Ste 606 Newport Beach, CA 92660
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