JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Virtual Consult Form
Please kindly fill out this form with as much detail as possible. The more complete your form the more data Dr. Cheng will have to offer you a valuable consultation. After you complete the form we will contact you for the next steps.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full name
*
Your answer
Email Address
*
Your answer
Please fully explain the concern that you would like Dr. Cheng to consult you on.
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Date of Most Recent Dental Exam
*
You don't have to enter an exact date. It could be an approximate.
MM
/
DD
/
YYYY
How often do see a dentist?
*
Every 3 Months
Every 6 Months
Every 12 Months
Not Routinely
Other:
What is your main concern?
*
Second Opinion for a Treatment Plan
Cosmetic Dentistry Consultation (e.g. Smile Makeover, Invisalign, etc)
Other:
Have you ever had complications from past dental treatment?
*
Your answer
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
*
Your answer
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
*
Your answer
Do your gums bleed sometimes or are they ever painful when brushing or flossing?
*
Your answer
Have you ever experienced gum recession, or can you see more of the roots of your teeth?
*
Your answer
Have you had any cavities within the past 3 years?
*
Your answer
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
*
Your answer
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
*
Your answer
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry food?
*
Your answer
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
*
Your answer
Are your teeth becoming more crooked, crowded, or overlapped?
*
Your answer
Are your teeth developing spaces or becoming more loose?
*
Your answer
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
*
Your answer
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
*
Your answer
Do you wear or have you ever worn a bite appliance?
*
Your answer
Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?
*
Your answer
Have you felt uncomfortable or self conscious about the appearance of your teeth?
*
Your answer
Please confirm that you will email all relevant documents (dental history, x-rays, photos and videos of your smile) to
info@drchengs.com
*
Sure, I will email all the documents to the address above for Dr. Cheng's review
Other:
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dr. Cheng's.
Report Abuse
Forms
