How many primary (baby) teeth will you have, counting your upper and lower teeth?

Choose One 16 10 20

How long will these primary teeth last before you start to get your permanent teeth?

Choose One Up to 6 years old Up to 9 years old Up to 12 years old

When should you brush your teeth?

Choose One In the morning, after breakfast and before bed Just before eating a sugary snack In the car, to drive your mom and dad crazy

What is fluoride?

Choose One The name of President Bush's ranch A mineral that strengthens teeth & prevents decay 20

What’s the right length of time to spend brushing your teeth?

Choose One 10 minutes 2-3 minutes 1 minute

Most people actually only spend this much time brushing their teeth:

Choose One 10 minutes 3-4 minutes 1 minute

What should I do if a tooth is knocked out?

Choose One Forget about it -- you'll look tough! Wrap the tooth in a clean cloth and call us. Rinse the tooth off, place it in milk and call us

What’s a dental seal?

Choose One A little seal who lives in our waiting room A clear plastic that sticks to your teeth to keep food out and reduce tooth decay A gold star you get when you have a perfect checkup

Tell us about you
* = requires an answer

Your Name:* 

Your Age:*

Your Grade:

Have you been to see Dr. Steve or Dr. Shari before?  Choose one Yes No

Your e-mail address:*