Quick Implant Questionnaire

Personal Info

Name *

Phone *

Email *

Postal Code *

Birth Year *

How did you hear about us? *

Quick Implant Questionnaire

What bothers you the most about your current dental condition/smile ? What is your main concern? *

How many teeth are you missing? *

Have you been told you need to have your teeth extracted? *

Have you ever been told that you have gum disease? *

Do you smoke? *

Do you have diabetes? *

Have you ever been told that you grind your teeth? *

Do you have any root canaled tooth in your mouth? *

Have you ever used denture (fake) teeth to replace 1 or more teeth? *

Have your mom or dad lost teeth when they were less than 50 years old? *

Have you ever had radiation therapy? *

Have you ever had chemotherapy? *

Have you ever been diagnosed with osteoporosis/osteopenia? *

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LEGAL DISCLAIMER

Final, conclusive diagnosis will be determined after iCat scan.

Virtual/Technology Consult Disclaimer:

As with any medical procedure, there are potential risks associated with the use of telemedicine/telehealth. These risks include, but may not be limited to:

In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled online appointment.
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
All vendors used by the practice in providing telehealth technology are required to comply with the requirements of HIPAA; however, in very rare instances, security protocols could fail, causing a breach of the privacy of personal medical information.

Quick Implant Questionnaire

Quick Implant Questionnaire

(331)-257-7999

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