MMV - Cancun Dental Assessment Form

Your Dental Assessment

Welcome to Gorgeous Getaways !! Please be so kind to fill this assessment along with your medical information. Also please upload your panoramic x-rays as well as your photos. We will forward these to our Head Surgeons for feedback and a confirmed price.
When are you planning to travel?

Immediately1 to 3 months3 to 6 months6 months to 1 yearNot determined
What dates do you have in mind?

MonthDayYear
Date
Do you want to combine your Dental Treatment with other surgeries in the same trip ?

Bariatric and ObesityCosmetic SurgeryFertility and ReproductiveOther

About You
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Photos & Files
UPLOAD YOUR DENTAL PANORAMIC X-RAYS OR DENTAL CT-SCAN
This is a valuable tool and required by your dentist to assess the areas of your mouth that you would like to address. It can be no more than 6 months old and can be obtained with your local dentist.

UPLOAD YOUR DENTAL PHOTOGRAPHS
Taking photos of your teeth is also required.

1. Photographs should clearly show your teeth as per the examples below.
2. Photographs should be recent and certainly not more than 6 month old.
3. Photographs should be clear, and in focus.
Please upload photos or files

Browse Files

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