Timisoara, Romania 0040 744 532 716 0040 356112724

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Complete the questionnaire below and you will receive an answer from the dental implant clinic specialists Timisoara. In order to get an estimate as close as possible to the final one, it is advisable to attach a recent photo with your smile that can be done even with your phone, as well as a panoramic digital radiography not older than a month. Photo is mandatory because it can be done with minimal effort and without a medical recommendation.

1.How many teeth have you lost?

1 tooth2-4 teeth5-10 teethalmost all

2.How long have you lost your teeth?

1 month2-4 months6-12 months1-4 years old4-7 yearsover 7 years

3.Which jaw do you think you need dental implants?

The upper jawThe lower jawBoth

4.What are the causes of tooth loss?

dental cariesimproper dental workperiodontal diseaseinjuryaccident

5.Do you suffer from one of the following general health conditions?

HypertensionMyocardial infarctionDiabetesMalignant diseaseAllergy to anesthetics or other substancesExtending bleeding / clotting timeSmokingI am a healthy personCurrent medication:(Check the box then write in the box below the treatment you are following)

6.How old are you?

16-25 years25-35 years35-45 years45-55 yearsover 55 years

7.Why do you want treatment with dental implants?

I do not want to polish my healthy teethI think it is a very good treatmentI wish I could chew correctlyI want a nice smileI want the best possible treatment regardless of costs

8.What type of offer do you want to receive?

price insertion dental implantsprice dental implants and prosthetic workprice with accommodation included near the PastelDent Clinic Timisoaraall inclusive: implants, work, accommodation, tourist program, airport transportation

9.Attach a recent photo

10.Attach a panoramic radiography, not older than 7 days

Name*


E-mail*

Phone*

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