Wisdom Tooth Extraction Registration
Text us at (281) 896-0974
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Name *
Age *
Mobile Number *
Email address *
Zip Code *
Current Pain Scale *
Not Painful
Extremely Painful
We will need a copy of your panoramic x-ray to be able to asses your case. Do you have one available from your previous dentist? *
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How many wisdom teeth do you want/need to be extracted? *
Can you tell us more about your problem tooth/teeth? *
Do you have any medical conditions, or are you currently taking any medications? *
Shirt Size *
Where did you hear about us? *
Anyone you wish to refer for this FREE 3rd molar extraction? Kindly leave their names and contact number here so we can call them. *
Who is Dr. Jared Williams?
Please note that we may place special priority on patients who need or want all 4 wisdom teeth removed.

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