Name |
|
Address |
|
Postcode |
|
Telephone |
|
Mobile |
|
e-mail |
|
How would you like us to contact you?
|
Telephone
E-Mail
Letter |
Are you a smoker?
|
Yes
No |
If yes, how many per day?
|
Daily Alcohol Consumption |
Units (1 Unit = Small Glass of Wine or Half Pint of Beer/Lager/Cider)
|
Do you regularly suffer from bleeding gums? |
Yes
No |
Do you regularly suffer from tooth infections? |
Yes
No |
How is your general health ? |
Good
Average
Poor
|
Do you suffer from Osteoporosis? |
Yes
No |
Do you suffer from any type of Immune Deficiency? |
Yes
No |
Are you currently taking any of the following? |
Aspirin
Phosphates
Suppressants
Warfarin. If you are taking Warfarin
what is your INR?
|
Do you take or have you ever taken Steroids? |
Yes
No
(Many Asthma, Hay Fever and Eczema Medications Contain Steroids) |
Do you suffer from the following? |
Eczema
Diabetes
Abnormal Bleeding
|
Do you suffer from periodontal problems?
|
Yes
No |
If yes, for how many years?
|
Have you worn dentures before? |
Yes
No |
If yes, for how many years?
|
Have you recently had an implant assessment or consultation?
|
Yes
No |
If yes, see ** below |
Have you had a Panoral X-Ray ? |
Yes
No |
Which age group category do you fall within? |
<25
25 - 34
35 - 44
45 - 54
55 - 64
65 - 74
75+
|
How often do you visit your dentist for an oral examination?
|
Twice a year
Once a year
Once every 2 years
Hardly ever
Only when I have a dental problem
|
How often do you visit your dentist/hygienist for a scale & polish? |
Twice a year
Once a year
Hardly ever
Never |
If you have recently had teeth extracted, when was this?
|
Within the past 3 months
3-6 months
6-12 months
12 months + |
What will be the most important factor when deciding whether to proceed with implant restoration?
(please enter 1 for most important, 4 for least, etc) |
Treatment cost
The final appearance
Clinic's reputation
Advanced technology |
Do you require finance before you proceed with implant restoration treatment? |
Yes
No |
Additional Comments
|
|
| ** If you have recently had an implant assessment or consultation, and would like to send us a copy of the report and/or treatment plan, then please do so. The information on a treatment plan will generally give us most of the information we require to prepare a cost estimate, which we will send within 5 working days for you to make a comparison. |
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