If you have a TMD or Sleep Disorder exam appointment scheduled click the appropriate button below to complete the new patient form before your examination.

If you do not have an appointment scheduled but would like one, please fill out the form below and we will contact you shortly.

 


Appointment Request Form

Name *
Name
Phone *
Phone
Are you aware of noises in the jaw joints?
Do your jaws feel stiff, tight, or tired after eating?
Do you have any sounds, feelings, or discomfort in your ear(s)?
Do you have bad headaches or migraines?
Have you had Orthodontic treatment?
Do you grind or clench your teeth?
Is stress/anxiety a problem?
Have you ever had whiplash or any head or neck trauma?
Best time to reach you
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