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Dental Med Form |
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Patient Contact Information |
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First Name: |
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Last Name: |
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Email: |
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Phone: |
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Mobile No: |
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Address: |
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City: |
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State: |
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Country: |
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Zipcode: |
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General Information/Statistics |
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Gender: |
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Height: |
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Weight: |
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Date of Birth: |
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Travel Infromation |
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What is your approximate date for your Dental Treatment? Month/Year: |
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Will you be traveling by yourself or with a companion or spouse ? |
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What is the number of days you would you like to go for ? |
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Will you need our services for hotels, travel, & tours ? |
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Have you ever had dental treatment done abroad ? |
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If so, which country ?
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Do you have a valid passport ? |
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If not, then would you require assistance in obtaining a valid passport ? |
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In order to give you the most accurate estimate we can, can you please respond the following questions to get the
clearest picture of what you need, what we're working with, and what we can do for you.
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I. Previous Diagnoses |
| What have you been told by your dentist that you need ? |
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Did you receive a formal diagnosed treatment plan for what you want to have done ? |
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Were x-rays taken? How long ago ? |
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II. Pre-existing state |
| Do you know what teeth you have missing on the top and bottom? Upper right,
Upper left, Lower right, Lower left: |
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How long have you been missing these teeth ? |
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What teeth do you have remaining on the top and bottom ?
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What significant procedures have you already had done? Crowns, implants, veneers, etc: |
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What dental devices do you currently have?
Bridge, Dentures, Crowns, Implants, Braces, etc: |
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Have you been told how many implants you need ? |
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Do you need an upper or lower jaw restoration
or both the jaws ? |
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If you are wearing dentures, do you wish implants to replace them ? |
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Would you prefer non invasive computer guided implants ? |
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III. Desire |
What would you like our dentists to do for you?
Relieve pain, Have a perfect smile, Fill gaps, Be able to chew properly again, Straighten teeth,
Whitening etc. |
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Do you have anything you'd like replaced as well ? Do you have anything you'd like replaced as well ? |
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IV. Budget |
| Do you have a particular budget you're working with today ? |
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Do you have any dental insurance coverage right now ? |
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V. Timetable |
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How soon were you looking to have your desire done ? |
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Why are you seeking treatment now, as opposed to any other time you could have done this ? |
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