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Submit your Dental History

Prostho-Implants Dental Associates submission form

Free Text

Patient Information

First Name:

Last Name:

Email:

Home Address:

City

State:

Zip Code

Phone:

Country

Emergency Contact

Emergency Phone:

Patient Dental History

Are you under treatment now?

Yes

Do you have any unhealed injuries or swollen areas in or around your mouth?

Yes

Have you experienced pain somewhere in your mouth?

Yes

Does any part of your mouth hurt when clenched?

Yes

Have you ever had local anesthetic?

Yes

Any reactions or allergic symptoms to local anesthetic?

Yes

Any complications with tooth extractions in the past?

Yes

Prolonged bleeding following extractions in the past?

Yes

Have you ever had instruction on the correct method of brushing your teeth?

Yes

Do your gums bleed?

Yes

Do you chew on only one side of your mouth?

Yes

If Yes, Why?

Do you have any dental issues at this time?

Yes

Do you brush/floss your teeth and use mouthwash on a daily basis?

Yes

When was your last full mouth X-RAY taken?

Yes

Do You Smoke?

Yes

Does any part of your mouth hurt when pressured or in contact with irritants? (cold, sweets, etc.)

Yes

If so, locate

Referred by:

Additional Comments

Thank you for contacting us. We will get in touch with you as soon as possible. Sincerely, Dr. Lorenzana

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DR. LORENZANA

LORENZANA DENTAL CENTER

TESTIMONIALS

DENTAL SERVICES

TOLL FREE 1-800-783-0198

Address:

Pasaje Sagrado Corazón #826,

Colonia Escalón,

San Salvador, El Salvador.

Phone: +(503) 2263-4572

Email: international@lorenzanadds.com

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Submit your Dental History

Prostho-Implants Dental Associates submission form

Patient Dental History

HOMEDR. LORENZANALORENZANA DENTAL CENTERTESTIMONIALSDENTAL SERVICES

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DR. LORENZANA

LORENZANA DENTAL CENTER

TESTIMONIALS

DENTAL SERVICES