Patient Contact Information
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| Last Name: * |
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| Email: * |
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Phone: * |
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| Mobile Phone |
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| Address # 1: |
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Address # 2: |
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| City: |
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State: |
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| Zip / Country Code: |
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Country: |
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General Information/Statistics |
| Gender |
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Height |
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| Weight |
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Date of Birth |
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Travel Infromation |
| What is your approximate date for your Dental Treatment? Month/Year |
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| Would you prefer, MEXICO, COSTA RICA, INDIA, THAILAND or POLAND? |
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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 the services of our Tour and Travel department for excursions? |
Yes
No |
| Have you ever had dental treatment done abroad? |
Yes
No |
| If so, which country? |
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| Do you have a valid passport? |
Yes
No |
| If not, then would you require assistance in obtaining a valid passport? |
Yes
No |
The image below is handy to figure out any questions related to your teeth location and to fill out the following questions: |
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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. |
| I Previous Diagnoses |
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| 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 |
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| 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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| Are you currently experiencing pain? |
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| When do you experience pain? Chewing, talking, etc. |
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| Where is the pain? |
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| Do you have any swelling in your mouth? Where? |
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| Do you have sensitivity in your teeth? |
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| When do you experience this sensitivity? |
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| Do you have any bleeding when brushing? |
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| III Desire |
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| 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? |
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| IV Budget |
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| 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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Your Dentist in U.S. |
| Please provide the name of your Dentist |
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| Phone |
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| E-mail |
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| Address |
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| Address #2 |
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| City |
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| State |
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| Zip |
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| Country |
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PLEASE NOTE: It is not necessary to fill out the below information yet. If your dentists abroad require the below information, we will contact you. However once you have decided to embark on your exciting Dental Med Journey Abroad the below information will be necessary. |
| Are you/have you ever had: |
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| Aids or HIV +ive |
Yes
No |
Anemia |
Yes
No |
| Arthritis |
Yes
No |
Asthma |
Yes
No |
| Back Problems |
Yes
No |
Blood Clots |
Yes
No |
| Blood Disorders |
Yes
No |
Bleeding Problems |
Yes
No |
| Breathing Problems |
Yes
No |
Cancer |
Yes
No |
| Chest Pains |
Yes
No |
Colitis |
Yes
No |
| Depression |
Yes
No |
Diabetes |
Yes
No |
| Ear Problems |
Yes
No |
Eye Problems |
Yes
No |
| Epilepsy |
Yes
No |
Heart Problems |
Yes
No |
| Heart Murmur |
Yes
No |
Hepatitis |
Yes
No |
| High Blood Pressure |
Yes
No |
Irregular Heartbeat |
Yes
No |
| Kidney Problems |
Yes
No |
Liver Problems |
Yes
No |
| Migraine Headaches |
Yes
No |
Nervous Breakdowns |
Yes
No |
| Nose/Throat Problems |
Yes
No |
Osteoporosis |
Yes
No |
| Pneumonia |
Yes
No |
Any psychiatric conditions |
Yes
No |
| Rheumatic Fever |
Yes
No |
Seizures |
Yes
No |
| Shortness of Breath |
Yes
No |
Skin Cancer |
Yes
No |
| Stomach Problems |
Yes
No |
Stroke |
Yes
No |
| Thyroid Problems |
Yes
No |
Tuberculosis |
Yes
No |
| Transfusion |
Yes
No |
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For Women Only |
| Do you take birth control pills or any hormone replacement medication or patches? |
Yes
No |
| Are you pregnant? |
Yes
No |
| (Pregnant women must take a pregnancy test before departure as most pregnancies can disrupt surgery) |
Medical History |
| In the past 18 months, have you been hospitalized, had surgery or received medical treatment, pregnancy delivery, or ambulatory surgery |
Yes
No |
| What was your date of surgery? |
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| What was your reason for surgery? |
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| Have you ever had weight loss (bariatric) surgery? |
Yes
No |
| Which procedure did you have? |
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| What was your date of surgery? |
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| What was your net weight change since surgery? |
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| Do you have any implants or metal objects in your body? |
Yes
No |
| A pacemaker? |
Yes
No |
| Plates, screws or other hardware from other procedures? |
Yes
No |
| Do you have difficulty with healing or scarring? |
Yes
No |
| Have you had cosmetic surgery in the past? |
Yes
No |
| If yes, please explain how your experience was: |
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| Please list any other past surgeries: |
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Medication |
| Kindly list all the medication you take, along with the dosage: |
| Are you allergic to any medication? |
Yes
No |
| If yes, please explain which medication(s) along with the reaction(s) |
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| Have you had problems with anesthesia? |
Yes
No |
| Are you allergic to any type of food or latex? |
Yes
No |
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| Do you take any vitamins or herbal supplements? |
Yes
No |
| If yes, please explain which ones: |
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| Do you smoke? |
Yes
No |
| If yes, how much do you smoke? Per day, per week, per month? |
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| Do you drink alcohol? |
Yes
No |
| If yes, how much? Per day, per week, per month? |
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| * Indicates required field. |
