Florida Dental Implant Institute Treatment Application

1

Name* This field is required.

First Name

Last Name

2

Mobile Phone Number* This field is required.

Please enter a valid phone number.

3

Concerns Your Are Experiencing* This field is required.(Check box if you are experiencing any of the following issues or concerns)

dental anxiety /sedation

hyperactive gag reflex

anxious about injections

“out of control” in dental chair

Social embarrassment

Loss of self-esteem

Loss of confidence from teeth

Headaches

Feeling older than you are

Difficulty chewing (pain)

Limitation of foods you can eat

Decreased taste of food

Difficulty speaking

Dentures/partials are painful

Must use denture adhesive

Food trapped /under teeth

Bad breath

Depressed about teeth loss

Traumatic dental experience

Difficulty dating due to teeth

Avoids eating in public

Ashamed to smile

Increased facial wrinkles

Denture / partial looks fake

Withdrawal from social interaction

Nutritional / digestive disorders

Avoid foods you love

Numbness where denture is

Partials make teeth sore

Denture / partial moves too much

Sores under denture /partial

Burning sensation

Difficulty sleeping

Teeth grinding (sore jaw)

4

Are You Currently Experiencing Pain or Discomfort?* This field is required.

YESNO

5

What is Your Main Dental Concern? * This field is required.

6

Please Rank the Cost of Dental Treatment and how it will influence whether you can get your dental treatment (Drag/Slide the Number Box Below)* This field is required.(1= will not keep me from getting dental treatment, 10= will very likely keep me from getting dental treatment)

7

Please Rank the Fear of Dental Treatment and how it will influence whether you can get your dental treatment* This field is required.(1= will not keep me from getting dental treatment, 10= will very likely keep me from getting dental treatment)

8

Please Rank My Availability/Lack of Time and how it will influence whether you can get your dental treatment* This field is required.(1= will not keep me from getting dental treatment, 10= will very likely keep me from getting dental treatment)

9

Rate how much your dental pain affects you (1= minimally, 10= severely):* This field is required.(Drag and drop the slider)

10

Rate how much embarrassment from your dental problems affects you (1= minimally, 10= severely):* This field is required.(Drag and drop the slider)

11

Rate how much eating difficulties from your dental problems affects you (1= minimally, 10= severely):* This field is required.(Drag and drop the slider)

12

Rate how much your dental problems affects your willingness to smile (1= minimally, 10= severely):* This field is required.(Drag and drop the slider)

13

Rate how much anxiety from your dental problems affects you (1= minimally, 10= severely):* This field is required.(Drag and drop the slider)

14

We treat a lot of patients who travel extensively and are not full-time South Florida residents. To effectively coordinate your treatment, do you have a special event and/or deadlines for your treatment to be completed by?* This field is required.

15

Do you have DENTURES or PARTIALS?* This field is required.

Dentures

Partials

Neither

16

If you have dentures or partials, how long have you had them and do you wear them everyday?

17

Dr Eberle lectures nationally and internationally regarding our unique and expert approach to Implant Surgery and restoration. Your confidentiality ensured, may we use your before and after dental x-rays for training purposes??* This field is required.

YESNO

18

Florida Dental Implant Institute frequently provides corrective surgery for patients who are unhappy with their results. Have you been involved with a medical/dental legal claim?* This field is required.

YESNO

19

Florida Dental Implant Institute frequently provides corrective surgery for patients who are unhappy with their results. Do you need any particular documents / reports prepared by our office?* This field is required.

YESNO

20

Kindly detail anything not covered above to help ensure your comfort and satisfaction during treatment:

21

I understand the above information is necessary to provide me with expert dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. You have my permission to ask the respective healthcare provider or agency for any further information, who may release such information to you. I will notify the doctor of change in my health and medication.

I hereby release this clinic for any indemnification or hold them harmless agains physical damage, personal injury, or accidents that might happen during and after the procedure.

I confirm that all information I provided in this form is accurate and true.

22

Patient Signature* This field is required.

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23

Date Signed* This field is required.

Date