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Page 1: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 2: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 3: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 4: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 5: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 6: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 7: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 8: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 9: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 10: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 11: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and
Page 12: perfectsmilesi.comperfectsmilesi.com/wp-content/uploads/2013/09/New-Patient-File.pdf · ____ Crowding/Crooked teeth ____ Jaw joint pain ____ Spaces ... Advances in technology and

Name_______________________

Email:________________________

Please Tell Dr. Rodriguez

What you don’t like about your teeth

____ Crowding/Crooked teeth ____ Jaw joint pain

____ Spaces ____ Missing Teeth

____ Tooth Size ____ Dark Teeth

____ Gummy Smile ____ Speech promblems

____ Underbite ____ Overbite

____ Teeth are different colors ____ Ugly old crowns

Other__________________________________________________________

Iam interested in

____ 6 Month Brace

____ Teeth Whitening

____ Veneers

____ Other _______________________________________________________

Is there anything you would like Dr. Roriguez to know?

_____________________________________________________________________________________

_____________________________________________________________________________________


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