Dr. Wael Garine, DDS
345 Jupiter Lakes Blvd. STE 304
Jupiter, Florida 33458
www.drgarine.com
Phone: 561-747-4272
Fax: 561-747-4294
E-Mail:www.drgarine.com

Want us to contact you? Should you have any questions and or concerns and would like to speak with us, please provide the following information:

Name:
Phone:
Referred By:
Reason for contact:
Good time to Call:
Preferred Appointment Times:

To help us be better prepared when we speak with you, please take a moment to provide the following information:

Are you currently experiencing problems?

If yes. Sensitive to:   Hot     Cold     Pressure

If you don't know the tooth number, please indicate the location of the tooth:

If you are experiencing pain, please explain. Pain is     Sharp     Dull      Constant     Periodic

When was your last dental visit?

At this appointment did you have:     a cleaning     X-Rays taken

Do you require Pre-Medication prior to your dental appointment?