Dental Implants in the UK from only £395

FREE DENTAL IMPLANT SUITABILITY ASSESSMENT (PRELIMINARY)

FOR ANY QUERY OR TO BOOK A CONSULTATION CALL: 01628 481532
WE CAN ALSO ANSWER ANY QUESTION YOU MAY HAVE ON THE ENQUIRY FORM

 

(ALL DETAILS ARE KEPT IN THE STRICTEST OF CONFIDENCE)

SELECT YOUR MISSING OR FAILING TEETH
(Type in ‘M’ for a missing tooth, or ‘F’ if the tooth is loose/failing)

UPPER JAW - AS A DENTIST IS LOOKING AT YOU
YOUR RIGHT SIDE
YOUR LEFT SIDE
UR8
UR7
UR6
UR5
UR4
UR3
UR2
UR1
UL1
UL2
UL3
UL4
UL5
UL6
UL7
UL8
 

LOWER JAW - AS A DENTIST IS LOOKING AT YOU
YOUR RIGHT SIDE
YOUR LEFT SIDE
LR8
LR7
LR6
LR5
LR4
LR3
LR2
LR1
LL1
LL2
LL3
LL4
LL5
LL6
LL7
LL8

Please also fill in the form below, completing all fields before submitting,

Name
Address
Postcode
Telephone
Mobile
e-mail
Confirm e-mail
Date of Birth (DD/MM/YYYY)
How would you like us to contact you?
Telephone     E-Mail     Letter
Are you a smoker?
Yes     No If yes, how many per day?
Weekly Alcohol Consumption
 Units (1 Unit = Small Glass of Wine or Half Pint of Beer/Lager/Cider)
Do you suffer from Osteoporosis?
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 chronic diseases?
 Diabetes     Abnormal Bleeding    High Blood Pressure  
Other 
Do you suffer from any of the following infectious diseases?
 Herpes     Hepatitis    Tuberculosis    HIV/AIDS
Other 
Do you suffer from periodontal problems (inc. loose teeth)?
Yes     No If yes, for how many years?
Do you suffer from bleeding/tender/swollen gums?
  Yes      No
Do you wear dentures?
 Full     Partial     No
Do you already have dental implant(s)?
  Yes      No
Have you recently had an implant assessment or consultation?
Yes     No If yes, see ** below
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
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 Click Here. 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.