Patient Name
What is your phone number?
Would you like to provide an email?
What is your primary reason for seeking my care?
What are the goals that you would like to achieve for yourself in working with me?
How long have you been experiencing these?
Do you have a timeline by which you would like to achieve the results you desire?
On a scale of 1 to 10 (where 1 is the least and 10 is the most), how much do you think dentistry influences whole body health including sleep, breathing, hormonal balance, behavioral issues, heart and gut health, healthy brain, and energy and vitality?
If you could conjure the exact process, experience and healing outcome you wish for, what would these look and feel like, for you?
What is compelling you to choose us as a part of your wellness team?
How did you find us?
If you were referred to us, whom may we thank for the referral?
What is your preferred means of contact?
What days and times work best for you?
What is your understanding of insurance coverage for Out Of Network practices?
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