First visit

At the first appointment, through a detailed discussion with you, we will get informed and understand what does not satisfy you in your smile, what are your concerns and what are your expectations.

Then, after the clinical and radiographic examination, we will formulate the treatment plan, always taking into account your wishes, needs and limitations.

Finally, we will take initial impressions to make “diagnostic casts”, on which we will design your new smile.

First date

*Name:

Date of birth:

Age:

Profession:

Address (street, number, zip code, city):

Home phone number:

Work phone:

*Mobile:

e-mail:

In addition, please answer the following:

Have you recently noticed a sudden weight loss?

YesNo

Have you been hospitalized in the last year?

YesNo

Have you undergone any surgeries?

YesNo

If so, which ones?

Are you allergic?

YesNo

If so, what?

Are you taking any medication?

YesNo

If so, what medications do you take and why?

Formulation:

Dosage:

Cause:

Formulation:

Dosage:

Cause:

Formulation:

Dosage:

Cause:

Other

Treating physician details:

In your opinion, is there any additional information that you believe your dentist should know about your history?

First visit

First visit

First date

Medical History

In addition, please answer the following:

Dental History

Questionnaire

Cosmetic Dentistry

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Cosmetic Dentistry

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