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PATIENT INFORMATION
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Name
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First
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Email
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Address
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How did you hear about this site?
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MEDICAL HISTORY
Have you had any surgery in the last 12 months?
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No
Yes
If you've had surgery in the last 12 months, please provide the details here:
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Have you had any dental procedures performed in the last 12 months?
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No
Yes
If you've had any dental procedures performed in the last 12 months, please provide the details here:
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HOW CAN WE HELP?
Please explain your dental problem and include any treatment previously received for the problem.
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WHAT ARE YOUR EXPECTATIONS?
Please explain your expectations of the dental treatment?
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PHOTOS
Upload photos that gives a clear view of the teeth you'd like treated.
Front view of clenched teeth
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Max file size: 2MB
Side view of clenched teeth
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Max file size: 2MB
Any photo of your teeth that you think your dentist needs
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Max file size: 2MB
PANORAMOGRAM
Upload the digital panoramogram file you received from your local dentist
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Max file size: 2MB
GENERAL
Which package are you interested in?
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What are your preferred travel and treatment dates?
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Is there anything else you'd like us to know?
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