Veneer Consult Form

Ladies and Kens let's make your Veneer experience amazing!

We are taking 6 dolls to Call, Colombia to get their new luxury smile by none other than Dra Venessa Giralda

The all inclusive 6 day/5 night trip includes

Airfare not included.
20 porcelain veneers (10 top, 10 bottom)
5 night stay in a fabulous horel where we will be staying and recovering together

Filer or Botox, spa, tour of city
Transportation
Meet & Greet
VIP dinner
$1000 deposit is required. Total due June 20.

Additional fees may apply if more dental work is needed. Each individual is different and will be evaluated prior to the trip.
Excursions and Additional activities services available upon request

Patient Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Dental Questionnaire

Rows	Yes	No
Do you get food caught between your teeth?
Do you have any missing teeth?
Do your gums bleed?
Do you have areas of receded gums?
Do you floss regularly?
Does gum disease run in your family?
Are your teeth hot/cold sensitive?
Teeth extracted?
Are your teeth sensitive to sweets?
Do you clench or grind your teeth?
Do you have a night guard/bite splint?
Have you ever had an oral surgery?
Do you have tired jaws?
Do you have orthodontics/braces?
Do you have popping or clicking in the jaw?
Have you ever had a periodontal treatment?
Do you chew on pens, fingernails, etc?
Have you had any injury to your face/jaw?
Do you drink coffee, tea or red wine?

Last Dental Visit

Date

Last Cleaning

Date

Medical Questionnaire

Rows	Yes	No
Heart surgery, disease, attack?
Blood transfusion?
Heart murmur?
Hemophilia or blood disorder?
Mitral valve prolapse?
Hepatitis A, B?
Heart attack or strokes?
Tuberculosis or lung disease?
Artificial heart valve?
Tumors?
Heart pacemaker?
Headaches or migraines?
Artificial joints (hip, knee, etc)?
Convulsions or epilepsy?
Neurological disorders?
Dizzy spells or fainting?
Rheumatic fever?
Cold sores or fever blisters?
Diabetes?
Thyroid disorder?
Kidney disease?
Stomach, intestinal, or colon disorders?
Jaundice or liver disease?
Cortisone or steroid therapy?
High blood pressure?
Possess the HIV or AIDS antibody?
Low blood pressure?
Psychiatric or psychological care?
Cancer?
Hay fever or airborne allergies?
Radiation or Chemotherapy?
Bruise easily?
Emphysema or asthma?
Venereal disease?

Do you have any other disease/condition/additional information not listed above? Type N/A if it does not apply.

Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration

What does your dream smile look like? Please explain.

Upload Wish Pic

Upload front teeth biting down

Upload Right Side Teeth biting down

Upload Left Side Teeth biting down

Upload Bottom Teeth mouth open

Upload Top Teeth mouth open

I, the above-named patient, understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Dental care has my permission to ask the respective health care provider or agency, who may release such information. I will notify this dental care facility of any and all changes in my health or medications. I consent to the performing of dental procedures agreed to be necessary or advisable, including the use of local anesthetics.Signature Date

Beauty Trip Form