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Wisdom Tooth Extraction Registration
Text us at (281) 896-0974
info@smileaftersurgery.com
Jaredwdds.com
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Email
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Your email
Name
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Your answer
Age
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Your answer
Mobile Number
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Your answer
Email address
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Your answer
Zip Code
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Your answer
Current Pain Scale
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Not Painful
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Extremely Painful
We will need a copy of your panoramic x-ray to be able to asses your case. Do you have one available from your previous dentist?
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Yes, and I will send a copy to
info@smileaftersurgery.com
None, but I will get one and send a copy to
info@smileaftersurgery.com
How many wisdom teeth do you want/need to be extracted?
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1
2
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4
Can you tell us more about your problem tooth/teeth?
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Your answer
Do you have any medical conditions, or are you currently taking any medications?
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Your answer
Where did you hear about us?
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Your answer
Emergency Contact and Phone Number
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Your answer
Anyone you wish to refer for this discounted 3rd molar extraction? Kindly leave their names and contact number here so we can call them.
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Your answer
Who is Dr. Jared Williams?
Disclaimer
Please note that we may place special priority on patients who need or want all 4 wisdom teeth removed.
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