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?
  • What dates do you have in mind?
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  • Do you want to combine your Dental Treatment with other surgeries in the same trip ?

  • About You

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  • Dental Needs

    Describe your dental needs below
  • Budget
  • Dental Category(s)
  • Dental Visits
  • Your Dental Goals

  • Universal numbering system for dental

    Below is the Universal numbering system for dental.  Please identify those teeth you are most concerned with. Provide a brief description of the problem for each quadrant. 

    The 4 quadrants are designated:

    • UR - upper right (1-8)
    • UL - upper left (9-16)
    • LR - lower right (17-24)
    • LL - lower left (25-32)

    Within each quadrant, the teeth are numbered as in the Palmer notation: 1-8 for permanent and A-E for deciduous, both starting at the midline.

  • Your General Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?
  • Allergies*
  • Smoking Habits*
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
  • Please rate your pain level*

  • 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.

     

     

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