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PLASTIC SURGERY
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DENTAL FORM
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Personal informations
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Age
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Medical History
Are you allergic to any medication?
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If yes, please list which medication(s) along with the reaction(s)
Are you under medical treatment?
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If Yes , please list them along with dosage
Have you had problems with anesthesia?
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If yes, please describe
Are you allergic to any type of food or latex?
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If yes, please describe
Do you take any vitamins or herbal supplements?
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If yes, please explain which ones
Do you smoke?
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If yes, how much do you smoke per day?
Do you drink alcohol?
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If yes, how often per week?
Do you have glycaemia?
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Do you have blood pressure ?
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Dental History
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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Do you know what teeth you have missing?
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How long have you been missing these teeth?
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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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Are you currently experiencing pain?
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If yes, please describe
What would you like our dentists to do for you?
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Do you have anything you'd like to be replaced as well?
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When are you planning to the procedure?
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