Yardley PA Dental Care

301 Oxford Valley Road Suite 404-A, Yardley, PA, 19067

Patient Forms

DENTAL HEALTH and APPEARANCE

Yes No SOFT MED HARD Yes No hot cold sweet sour none Yes No

  • Do you chew on only one side of your mouth?
    Yes No
    If yes, explain:
  • Do your gums feel tender or swollen?
    Yes No
    Do you usually have many cavities?
    Yes No
  • Do you clench or grind your jaws while sleeping or during the day?
    Yes No
    Do your jaws ever feel tired?
    Yes No
  • We respect your right to choose the level of care that fits your needs. We've found that many adults are unaware that problems even exist. There are rarely symptoms (pain, bleeding) associated with the aging and deterioration of teeth and gums - until it is far too late. According to the ADA, more than 80% of adult Americans have some level of gum disease. With your permission we would like to explain the choices available to achieve long-term health and beauty for your existing natural teeth. Please check all that apply:

  • I desire to keep my own teeth for life, if possible. I want my teeth to look good, feel good, and last for a long time
  • Spreading payments out over time may help me to achieve the excellent results I desire
  • Phasing treatment, by priority, over a few years may make it feasible for me to achieve the excellent results I desire
  • I am interested in a plan for long-term dental health. However, I am currently unable to pursue this, and would appreciate help with emergencies and cleanings for now
  • Although I am not interested in a plan for long-term dental health, I do desire an office who will treat teeth in need of immediate/emergency attention, as well as keep me up to date on cleanings.