YOUR PERSONAL INFORMATION

First name

Last name

Birthday

Day

Month

Year

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

YOUR MEDICAL INFORMATION

Please provide your medical history for an accurate evaluation of your treatment options.

I have had a serious illness in the past, have a chronic condition, or have allergies.

I am currently taking some medications.

I have an allergy or have had a reaction to anesthesia in the past.

I am pregnant.

I am taking some medications.

I have had surgery in the past.

I have previously undergone radiation therapy or chemotherapy treatments.

I am taking or have previously taken bisphosphonates (bone density medications).

YOUR ORAL & DENTAL HEALTH INFORMATION

Can you provide detailed information about the general health of your teeth, cavities, number of missing teeth, gum problems, pain, sensitivity, and any alignment issues with your teeth?

Can you provide brief information about any previous tooth extractions, fillings, root canal treatments, orthodontic treatments, and use of dentures?

Can you provide information about your oral hygiene? For example, your tooth brushing habits, use of dental floss, frequency of dentist visits, eating habits, and any other practices related to oral health?

Do you have any previous reports from a dental specialist (e.g., orthodontist, periodontist, etc.)?

INSURANCE INFORMATION

Do you have Private Dental Health Insurance?

TREATMENT REQUESTS & EXPECTATIONS

Can you describe any current issues or treatment needs related to your oral and dental health?

What treatments do you think are necessary?

Could you please share your expectations regarding the treatment? For example, you may expect an aesthetic smile, improved chewing function, pain-free oral health, or the completion of missing teeth. Please specify your preferences.

EXTRA INFORMATION

The requested photos below are important for us to properly plan your treatment.

Please share a profile photo where your face is fully visible from the front.

Please share intraoral photos where both your upper and lower teeth are clearly visible.

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REQUEST REPORT Form