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Dental History | Form 600

Welcome to Lxuoral patient portal page! We are thrilled to have you as a new patient and committed to continuously serving our existing patients. At luxoral we believe in delivering the highest standard of care possible. To ensure a better and pleasant experience with Luxoral, we kindly ask you to fill out all the required forms, including our new patient information form, health history form, dental history form, HIPAA consent form, and privacy of practice form. Thank you for choosing Luxoral, and we look forward to seeing you soon!

Dental History | Form 600

Personal Information

Birthday

Dental History

Have you had deep cleaning (SRP) done?
Does your jaw click, pop or hurt?
Have you had oral cancer screening?
How often do you brush your teeth?
How often do you floss your teeth?

Check the boxes below if you experiance any of these symptoms

Luxoral Dental Hygiene Practice
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