SSI - Consultation Form

Thank you for visiting Surgical Services International Dental Consultation Form. We will forward your medical details to your surgeon who will reply with his/her clinical evaluation and any questions he may have for you.

Full Name:	(First, Last)
E-mail:

Home phone: *
Work phone:
City of Residence: *
Preferred contact:	E-mail Phone
Birthdate (mm/dd/yyyy): *	/ /
Sex: *	Male Female
Height : *
Weight: *

Please describe exactly which procedures you are interested in and specify according to the chart the following information that pertains to your case:

Which teeth need implants
Which teeth need crowns
Which teeth need to be extracted
Which teeth need gingivitis treatment
Which teeth have been extracted and if so, when were they extracted
Bridges or crowns that you currently have
Any other procedures regarding your dental needs

Upper teeth:

Lower Teeth:

If necessary, please give us a brief overview of your dental history. Include any underlying cause of tooth loss or decay:

Have you seen a dental implant specialist or dentist? Have they determined that you are good candidate for implants and that you have enough bone density? Please describe:

Can you forward X-rays? If yes, please attach them below or you can do it later by email:

Document 1:
Document 2:
Document 3:

Medical History.
Medical History
List any medications you take including herbal medications :
List all major illnesses or injuries (diabetes, high blood pressure, emphysema, heart attacks, etc):
Do you have any allergies to medications? *	Yes No
If yes, please list the medications:

Social History
Do you smoke? *	Yes No
If so, how much?	packs / day
Do you drink alcohol? *	Yes No
If so, how much?	drinks / day

Do you currently have any problems in the following areas?
	Yes	No	If yes, please explain:
General / Constitutional (fever, weight loss, other)
Ears, Nose, and Throat (cold, sinus, chronic cough)
Cardiovascular (heart, vessels, etc.)
Respiratory (asthma, emphysema, etc.)
Gastrointestinal (ulcers, intestinal disease, etc.)
Genital, Kidney, Bladder
Skin (rosacea, skin cancer, psoriasis, etc.)
Neurological (MS, stroke, seizures, etc.)
Psychiatric (anxiety, depression, etc.)
Endocrine (diabetes, thyroid, etc.)
Blood / Lymph (bleeding disorder, high cholesterol, anemia, etc.)
Allergic / Immunologic (lupus, hay fever, rheumatoid arthritis, etc.)