Dental Implant Consultation Request
Date: ______________________
Introducing: ____________________________________________________________
Please evaluate for:
- Extraction Socket preservation
- Dental Implant Placement
- Ridge Augmentation
- Soft Tissue Graft Esthetic Attached Tissue
Indicate teeth/area(s) below:
Maxilla 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
_________________ _________________
Mandible 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
- Single Tooth
- Replacement Multiple Teeth
- Full Arch Reconstruction
Implant Preference:
- Straumann
- Ankylos
- Neodent
No Preference
Treatment Plan Preference:
Edentulous: Fixed Locations: ______________________________________________
Immediate Load Delayed Load
Hybrid Over Denture Traditional Crown & Bridge
Removable Locator Placement
Bar Over Denture
Temporization: Flipper Essex Immediate Denture
Temporary Crown & Bridge Temporization In My Office
Temporization to be delivered to Dr. Vinh Nguyen’s office
Surgical Template: To be delivered before surgery Not requested
Comments
Referring Doctor: _______________________________________________________
