Dental History for Adolescents and Adults Form

Fill out your form online or download a copy.

Dental History for Adolescents and Adults

Dental History for Adolescents and Adults Form

  • If YES, please indicate the name and phone number of the dentist.
  • If YES, please describe.
  • If YES, please indicate dentist's name and office phone number.
  • Please specify.
  • If YES. Please list what you wish you could change about the appearance of your teeth. Examples: Color, Shape, Spacing, Crowding, Other.
  • If YES, please indicate the brand and type.

Call The Office

(912) 489-1386
Fax: (912) 764-8533

Office Location

2 Lester Court
Statesboro, GA 30458
Located across from Statesboro High School.