Susana C. Chua, D.M.D
Yvette C. Chua, D.D.S
Derrick O.Chua, D.M.D

Information for New Patients

New Patients Questionaire

A note about privacy: Chua Dentistry respects the privacy of all current and potential customers. We will honor any information you submit to us with our utmost care.

Online Patient Registration

Please submit as much information as possible so we can better assess your needs and create a dental plan to best serve you.

Please complete the form below. Mandatory fields marked *

Personal Information

1. First Name *
2. Last Name *
3. Address
4. City
5. State
6. Zipcode
7. Phone *
8. Email *
9. Date of Birth:* Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 1911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992
10. Sex * FemaleMale
11. Is this regarding a dental emergency *

    Yes No

Dental Information

1. When was your last dental checkup?

   Less than 1 month Less than 3 months Less than 6 months Less than 1 year ago 2 years or more Don't remember!
2. Are you in discomfort?

   Yes No
3. How do you prefer we contact you?

   Phone Email
4. Any specific area that concerns you?
5. Additional Information: