tmjmigraineheadache.com - Appointment Request

For a free telephone consultation with Dr. Hoang, please check this box and fill out the form below.

Name

Phone

Email

*please check all that apply

Are you aware of noises in the jaw joints?

Option 1 Option 2 Option 3

Do your jaws feel stiff, tight or tired after eating?

Option 1 Option 2 Option 3

Do you have any kind of sounds, feelings or discomfort in your ear(s)?

Do you have neck or shoulder discomfort?

Option 1 Option 2 Option 3

Do you have bad headaches or migraines?

Option 1 Option 2 Option 3

Have you had Orthodontic treatment?

Option 1 Option 2 Option 3

Do you grind or clench your teeth?

Option 1 Option 2 Option 3

Is stress/anxiety a problem?

Option 1 Option 2 Option 3

Have you ever had a whiplash or any head and neck trauma?

Option 1 Option 2 Option 3

comments

Best time to reach you:

Day

Option 1 Option 2 Option 3

evening

Option 1 Option 2 Option 3

Preferred Appointment Day:

Preferred Appointment Time:

How did you find us?

Security Code *