Online Office

In Dallas, Fort Worth, Garland, Irving, and Plano, Texas

972.732.1818 Email Us

Smile N' Share It Cosmetic Dentistry
1320 Village Creek Suite #100
Plano, Texas 75093

Dallas Cosmetic Dentistry Disclaimer: The cosmetic dentist at Smile and Share It have provided this website for
informational purposes only. It is not intended to provide medical or dental advice nor does
the use of this site create a dentist-patient relationship.

Home
Patient
Financing
News &
Events
Online
Office
About
Us
- Meet the Team
- Choosing a
  Cosmetic Dentist
Cosmetic
Dentistry
Neuromuscular
& TMJ
Before
& Afters
Your
Consultation
Contact
Us

Welcome to Plano, Texas Cosmetic Dentist Dr. Avant's web site. Please upgrade your Flash player and/or enable Javascript to experience the whole site.

Today's Date	Marital Status:
Your Personal Health History
* First Name	* Last Name
* Your Email Address
Address
City	State	Zip
* Home Phone	Date of Birth	Soc. Sec #
Your Employer		Work Phone
Employer Address
Spouse's Name	Date of Birth	Soc. Sec #
Spouse's Employer		Spouse's Phone
Who referred you to our office?
Financial Information
Person Responsible for Payment		Relationship
Name of Primary Insured		Dental Ins. Co
Insurance Group #		Dental Ins. Phone #
Address for Insurance Claims
Dental History
Describe any discomfort you're having today
What is your major dental concern right now?
When was your most recent dental examination or treatment?
Checkmark all of the following which apply to you:
Teeth are sensitive to cold, heat, pressure, or sweets	Frequent or severe headaches	Orthodontic Treatment
Bleeding Gums Since when?	Jaw clenching	Had unfavorable previous dental experience
Food get trapped between teeth	Pain around either ear. Which ear?	Use toothbrush How often?
Grinding or gritting of teeth	Complications from tooth extractions	Use toothpicks How often?
Lumps or swelling in mouth	Periodontal treatment	Use dental floss How often?
Use Mouthwash How often?	Use tobacco How often?
Describe any other tooth, mouth, or jaw problems previously diagnosed by a dentist or physician, or other problems you believe may be affecting your dental health:
Medical History
Date of the most recent physical exam		Physician's Name
Checkmark all of the following which you now have or have ever had:
Allergic reaction to any drug	High blood pressure	Kidney problems
Allergic reaction to anesthetic	Any heart ailments	Liver problems or hepatitis
Excessive bleeding from cut or extraction	Rheumatic fever	Malignancies
Anemia or blood problems	Diabetes	Tested HIV-positive
Venereal disease	Stroke	Tuberculosis
Ulcer or colitis
Are you now pregnant?
Yes	No	If so, in what month of pregnancy?
List all medication you are currently taking, including both perscription and over-the-counter medicines:
Describe briefly all medical treatment you are currently participating in, whether or not it is mentioned in the preceding checklist:
Your Smile
How do you feel about the color of your teeth?
Are you happy with the shape and size of your teeth?
When you smile, do you feel you show too much gum tissue?
If you could change anything about your smile, what would it be?
Do you have any other questions or concerns?

Online Office

In Dallas, Fort Worth, Garland, Irving, and Plano, Texas

Your Personal Health History

Financial Information

Dental History

Medical History

Your Smile