WISDOM TEETH ENQUIRY FORM
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth: (eg: 13/08/2020)
*
Age:
*
Best time to call:
*
AM
PM
How did you hear about us?
*
Google
Instagram
Facebook
Friend/Family
Other
OPG X-ray (REQUIRED). If you don't have an OPG (see example below) that is less than 12months old, let us know & we will arrange a FREE referral for you.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a current OPG X-ray?
*
No. Please arrange a free referral for me.
Yes. Uploaded above.
Please send us 2 photos like the examples below. One with your mouth open as wide as possible and One with your mouth closed and fingers pulling your cheeks out as far as possible.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you anxious about the procedure and do you think you would prefer to be asleep (under general anaesthetic sedation)?
*
YES
NO
Please list any relevant Medical History here:
*
Please list all current medications here:
*
Do you take any form of Bisphosphonates?
*
Yes
No
Unsure
Do you have any known bleeding disorder/s?
*
Yes
No
Unsure
Are you immunocompromised?
*
Yes
No
Unsure
Do you have diabetes?
*
Yes
No
Is your diabetes currently controlled/managed?
*
Yes
No
Unsure
Not applicable
Submit
Should be Empty: