New Patients Trust your smile to an experienced cosmetic dentist. We can’t wait to meet you! Please bring the following items: Your photo identification A list of your current medications Your insurance cards and information A completed copy of the New Patient Information Form A completed copy of the HIPPA Notice of Privacy Practices Form If you are coming from another dental office please request that your records be transferred to: Thomas K. Broering, DDS, Inc. 710 E. Monroe St. P.O. Box 179 New Bremen, OH 45865 Important new patient forms New Patient Information Print this Form HIPPA Notice of Privacy Practices Print this Form Smile Analysis Survey Name Complete our Smile Analysis Survey to see what options are available for you! Your smile affects your self-image, and can greatly influence the quality of your interactions with others. Many people hold back from laughing or smiling because they are uncomfortable with their teeth. The following questions will help you appraise your smile. Go to the mirror, smile as wide as you can and ask yourself the following questions: First Name * Last Name * Phone Number * Email Address * Are any of your teeth turned, crooked, or uneven? * Yes No Would you like your teeth to be whiter? * Yes No Are any of your teeth yellow, stained or somewhat discolored? * Yes No Do you have gaps or spaces between your teeth? * Yes No Are you missing any teeth? * Yes No Do you have any prior dental work that appears unnatural? * Yes No Do you have any crowns or bridges that appear dark at the edge of your gums? * Yes No Are the edges of your teeth worn down, chipped, or uneven? * Yes No Do any of your teeth appear too small, too short, too large or too long? * Yes No Do you have any unsightly fillings in your teeth? * Yes No Are there any pitting or defects on the surfaces of your teeth? * Yes No Are your gums red, sore, puffy, bleeding or receded? * Yes No Do you have a gummy smile (too much of your gums show when you smile)? * Yes No Does the appearance of your smile inhibit you from laughing or smiling? * Yes No Would you like to change anything about the appearance or your teeth or smile? * Yes No If you answered yes to any of these questions, or have other concerns, please call or email our Dental Team to arrange your free consultation. Many options are available to best meet your individual needs and desires. You can have the smile you have always wanted!