Suitability Assessment

Dental Implant Suitability Assessment

CONFIDENTIAL FREE INITIAL DENTAL IMPLANT SUITABILITY ASSESSMENT

Please give us as much information as you possibly can. Feel free to ask us if you need any help in answering the questions. We will be able to provide a preliminary estimate based on your assessment which can be confirmed after a complete clinical assessment

If you have recently had an implant assessment or consultation, and would like to send us a copy of the report and/or treatment plan, then please feel free do so. The information on a treatment plan will generally give us most of the information we require to prepare a more accurate estimate. You can email, fax or post them. We will provide you a comparative assessment within 5 working days.

Your Contact Information








Preferred Practice

Please let us know which of our practices you would prefer to attend





Patient Details


IF YOU KNOW THE TOOTH/TEETH YOU WISH TO REPLACE , please give information in the box below, including when and how the tooth/teeth were lost


OR

USE THE DIAGRAM ON THE RIGHT to let us know which teeth are MISSING or FAILING

Upper jaw (as the dentist is looking at you) UR1 is the tooth in the centre of your mouth on the upper right hand side. Count backward from the centre tooth to find the number e.g. UL3 for teeth missing or failing.



Health Survey Questions
Are you a smoker?



Alcohol Consumption


Do you regularly suffer from bleeding gums or gum disease?


Do you regularly suffer from tooth infections?


How is your general health?



Do you suffer from Osteoporosis and are on intravenous bisphosphonates?


Have you had radiotherapy in the jaw region recently?


Do you suffer from any type of Immune Deficiency?


Are you taking warfarin?



Have you taken Steroids in past 2 years?


If Yes, when and what dose taken

Do you suffer from Uncontolled Diabetes?


Do you suffer from Abnormal Bleeding?


Are you currently taking any other medications?


Please list if yes and indicate what dose is taken

Have you worn dentures before?


If yes, for how many years?

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