+ Our COVID-19 Response: Find out the steps we are taking to keep you safe and healthy
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Accreditation
Veneers
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Sedation
general
Services
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Sleep Apnea / Snoring
reconstructive
sedation
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about
Meet Dr. LaCosse
Our Team
Our Practice Philosophy
What Our Patients Say
gallery
new patients
Make Appointment
Financial Options & Insurance
Pre-registration
Patient Portal
Before & After Gallery
Patient Reviews
pre-register
Pre-registration
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Insurance through your employer?
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Insurance Company Name
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Other Dental Insurance?
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Insurance Company
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Insurance Through:
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Name of Policy Holder
Their Social Sec. Number
Their Birthdate
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Reason for Visit
Date of Last Dental Visit
Date of Last Cleaning
Date of Last X-rays
Was any treatment recommended that was not completed? If yes, please explain.
Have you ever had Braces?
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no
Have you ever had Oral or Periodontal Surgery?
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no
Have you ever experienced pain or discomfort in or around the jaw joint (TMJ)?
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no
Are you anxious or uncomfortable about coming to the dentist? Anything you want us to know about your anxiety?
Are you currently in pain?
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no
Where is your pain?
What do you think are your major dental needs at this time?
Do you feel your teeth are too long or too short?
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no
Do you feel your teeth are too wide or too narrow?
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no
Do you feel your teeth are too square or too round?
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no
Are you self-confident about smiling in front of other people?
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yes
sort-of
no
Would you prefer to have straighter teeth?
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yes
sort-of
no
Do you like the way your teeth are shaped?
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yes
sort-of
no
Do you feel you photograph better from one side of your face?
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yes
sort-of
no
When you look at your smile in the mirror, do you see a minor defect in your gums or teeth?
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yes
sort-of
no
Are you satisfied with the way your gums look?
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yes
sort-of
no
Do you think you show too much or too little gum tissue when you smile?
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yes
sort-of
no
Would you like it if your teeth were whiter?
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yes
sort-of
no
Do you feel you show too many or too few teeth when you smile?
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yes
sort-of
no
Is there anything you would change about your teeth or your smile if you could?
Have you ever been involved in dental or medical legal activity?
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no
Information is Correct?
I understand that the information given today is correct to the best of my knowledge.
Agree to pay for services?
I understand the financial policy and agree to pay for any service rendered.
Authorize release of information for insurance claim?
I hereby authorize release of any information relating to any insurance claim and authorize payment directly to Lake Dental the group insurance benefits otherwise payable to me.
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