dental consultation online – Online Dental Consultation:

Please fill out this form carefully and in full.

online dental consultations

dental consultation online: This forms are used for collecting the data necessary to provide you Dental Consultation Online & Dental Second Opinion Online services. All the collected information are used to make ever more accurate diagnosis and predictions.

 

Section One: YOUR DETAILS

All information is strictly confidential. To see how we use your information, please read our privacy notice.

In this section fields are obligatory for filling. (*)




Age (*)

Sex (*)
FemaleMale
Where do you live? (City - State) (*)


Mobile phone / Whasapp phone (*)

Preferred contact method (*)
MobileWhatsappEmail
Choose the service that's right for you: (*)
ONLINE DENTAL EXAMINATIONDENTAL SECOND OPINION – ONLINE REVIEW OF YOUR DENTAL TREATMENT PLANONLINE EVALUATING ONGOING DENTAL THERAPYONLINE MEDICAL EVALUATIONS AFTER DENTAL TREATMENT
Do you need an urgent REPORT? (*)
NO (4 days delivery)YES (2 days delivery - a urgent fee of $35 will be added)
Let us know where to send you the report (*)
I prefer to receive by mailI prefer to receive by WhatsAppI prefer to receive on both Email and WhatsApp

Section Two: What Are Your Expectations?

In this section all fields are optional. Your responses help us better understand the diagnostic framework and provide better solutions.

How do you rate your dental health?
goodfairpoor
What is important to you? (check one)
The highest quality dentistry availableThe most economical treatment planGetting a solution between highest quality dentistry and most economicalDentistry limited to insurance coverage
To help us provide the best treatment, we would appreciate it if you could indicate below which treatments interest you.
Regular routine dental checks and maintaining good dental healthReturns to normal chewing and occlusal functionCosmetic treatment, improving the look of your smileDental implantsTreatment of pain

Section Three: Your dental history

In this section all fields are optional. Your responses help us better understand the diagnostic framework and provide better solutions.

It is important for us to have your dental history and understand your health needs before any examination of your dental case.
PLEASE INDICATE IF YOU SUFFER FROM OR ARE CONCERNED ABOUT ANY OF THE FOLLOWING, AGAIN THIS WILL HELP WITH THE TREATMENT WE PROVIDE FOR YOU.


Are any of your teeth mobile?

Are your teeth sensitive to: Hot, Cold, Sweet, Biting /Chewing or pressure?

Are you having pain at this time? If yes, describe where:

Do your gums bleed easily, feel tender or irritated?
yesno
Do you suffer from mouth ulcers?
yesno
Do you suffer from “dry mouth”?
yesno
Do you suffer from bad breath?
yesno
Do you have bad taste in your mouth?
yesno
Do your jaws feel tired when you wake up?
yesno
Have your jaws ever clicked or popped when you open your jaw?
yesno
Do you suffer from chronic headaches of any kind?
yesno
ABOUT ALL YOUR DENTAL TREATMENTS
If you have a denture, is it satisfactory? If not, why?

If you have Crown and bridge, is it satisfactory? If not, why?

If you have Aesthetic dental treatments, is it satisfactory? If not, why?

If you have dental filling, is it satisfactory? If not, why?

Have you ever had orthodontics (braces)?
yesno
Have you ever had gum treatment?
yesno
Have you ever had an injury to your teeth or jaws?
yesno
DO YOU HAVE ANY OF THE FOLLOWING HABITS?
Do you clench or grind your teeth during the day?
yesno
Have you ever been aware of clenching or grinding your teeth at night?
yesno
Hold/bite foreign objects
yesno
Bite your lips or cheeks
yesno
Mouth breathe
yesno
Do you chew on only one side of your mouth?
yesno
Do you smoke?
yesno
LAST DENTAL VISIT:
When did you last visit the dentist and what did you have done?

What was the reason for your last dental visit?

When did you last have an X-Ray (dental or otherwise)?

PAST DENTAL EXPERIENCES
Are you unhappy with any dental treatment received in the past?

Have you ever had any ill effects following dental treatment?

Have you ever had an upsetting experience in a dental office? If so, describe.

WHAT WORDS BEST DESCRIBE YOUR PAST DENTAL EXPERIENCES? Good value, Comfortable, Relaxed, Painful, Stressful, Uncomfortable, Bad Value

YOUR FEAR OR PHOBIA OF THE DENTIST:
Are you anxious patient about dental treatment? If yes, how anxious?

Do you want/need sedation for treatment?
yesno
Has the fear of discomfort kept you from regular visits?
yesno
ORAL HYGIENE:
What do you use to clean your teeth at home?

How often do you brush your teeth?

Do you use anything to clean between your teeth?

Do you use a mouthwash? If yes, how often?

Section four: Your Medical History

In this section all fields are optional. Your responses help us better understand the diagnostic framework and provide better solutions.

Your health history can be helpful in determining what treatments and procedure are best for you.

PLEASE INDICATE IF YOU SUFFER FROM OR ARE CONCERNED ABOUT ANY OF THE FOLLOWING, AGAIN THIS WILL HELP WITH THE TREATMENT WE PROVIDE FOR YOU.



Do you suffer, or have you suffered from any of the following? Abnormal Bleeding, Allergy, Anemia, ,Angina, Arthritis, Artificial/Prosthetic joint, Asthma or hay fever, ,Blood disorders, Bone or joint disease, Cardiac pacemaker, Cardic defect Congenital heart lesion, Diabetes, Epilepsy, Fainting or dizziness, Gastric reflux, Heart Attack, Heart Murmur, Heart trouble, Hepatitis, Hiatus hernia, High Blood Pressure, HIV/AIDS, Jaundice, Hepatitis, Latex sensitivity, liver disease, Low blood pressure, low blood sugar, Lung Disease or breathing difficulty, Osteoporosis, Rheumatic fever, Stomach trouble, Stroke. If yes please specify.

Have you ever had, or are you being treated for, any diseases or problems not listed? - If yes, details:

Are there any other aspects concerning your health that you think the dentist should know about? If yes, please specify:

Are you receiving any form of treatment from a doctor? If yes, please specify:

Are you Taking any medicines from your doctor (tablets/creams/injections)? If yes, please specify:

Have you ever had a prolonged illness or been hospitalised?
yesno
Have you had any major/serious operations or radiation therapy?
yesno
Have you or any relation had any severe prolonged bleeding problems?
yesno
WOMEN ONLY:
Have you had a baby in the last 12 months?
yesno
Are you pregnant or is it possible you may be pregnant?
yesno

Section Five: Your Uploads In evaluating the diagnostic we rely on a number and type of clinical and instrumental investigations.
Default acceptable file types (extensions) are: jpg, jpeg, png, gif, pdf, doc, docx, ppt, pptx, odt, avi, ogg, m4a, mov, mp3, mp4, mpg, wav, and wmv.



If you chose the service “ONLINE DENTAL EXAMINATION” upload these files:

The Panographic x-ray (Pano)



ADDITIONAL FILES HELP US MAKE A MORE ACCURATE DIAGNOSIS

Periapical x ray

Other types of x-rays (Bite-Wing X-Rays, Occlusal X-Rays, Tmj X-Ray, Cephalogram X-Rays, Sialogram)

Intra-Oral Photographs

Extra-Oral Photographs (Pictures of Mouth / Your Smile pictures)

To send Cone-beam computed tomography:

Cone-beam computed tomography it's a large file. You will be able to send your CT by WeTransfer service (https://wetransfer.com). WeTransfer service it very simple, reliable, fast and free. Send it separately after completing this form. Send it to this email: bigfile@dental-second-opinion.com

OUR AGREEMENT


ABOUT THIS WEB SITE

The information provided on this Web site is for general informational purposes only. We cannot make any representations, warranties, or assurances as to the availability, accuracy, or completeness of this website, its information or its contents. We shall not be liable for any damages or injury resulting from your access to, or inability to access, this website, or from your use of, or reliance on, this website or any information provided at this Web site. This website may provide links or references to other sites and may be accessed by links from third party websites over which we have no control. We have noresponsibility for the content of such other sites and shall not be liable for any damages or injury arising from that content or that access. Any links to other sites are provided as merely a convenience to the users of this website. We reserve the right to delete, modify or supplement the content, links or references of this site at any time, for any reason, without notification. By accessing or using this website, you acknowledge that you have read, understood and agree to this Terms of Use Agreement. If you do not agree to the Terms of Use, you may not access or use the site.

ABOUT OUR SERVICES

Although dental x-rays, TAC and images offer a vast amount of information, they do not show everything, so an incomplete or incorrect diagnosis is always a possibility.
As this is an online service, there is no clinical examination, and therefore, a complete oral examination including oral cancer screening can only be done in person.
Since we are only online, an official diagnosis can only be done in person.
If you do not agree with this disclaimer, you may not use our services.


I accept the agreement: