E-Consult Form

All information associated with your e-consult submission will remain strictly confidential and will not be distributed or published unless you provide us with written consent for release of such information.

Please fill out the e-consult Registration form and provide us with the any of the items listed below:

• A detailed and accurate description of the proposed treatment which includes specific teeth to be treated along with the dental terms.
• A Scanned copy of the treatment plan printout provided by your dentist is usually adequate.
• A Scanned x-ray or photograph of tooth/teeth. Film x-rays should be scanned at a minimum of 300dpi, digital x-rays can be e-mailed to you from your dentist's office and then attached to this e-consult request.
• An accurate description of your health with a complete list of medications (dosage and regimen) you are currently taking or have taken recently.

It should be understood that the e-Consult is NOT a substitution for a clinical examination or Xray. The opinions offered are purely based on a set of hypothetical scenarios or recollection of events as the quality of the images and quality of the limited information you provide at the time of submission. We endeavor to provide as accurate a treatment plan as possible but please be advised that in some cases treatment plans will need to be altered once an xray has been studied.
Basic Patient Info
Patient Name: Date Of Birth (DD/MM/YY):
Address 1: Telephone No:
Address 2 / Town: Mobile Tel:
Postcode: Fax:
County/State: Email:
Country:    
Place of Referral
How Did You Hear About Marbella Dental:
Dental Health
Reason For Requesting an e-Consult (proposed dental treatment / existing condition / second opinion, etc...):
When Was Your Last Dental Visit And What Was Discussed?
Have You Ever Had Serious Problems Associated With Previous Dental Treatments? If Yes, Please Explain:
Are You A Smoker? If Yes, How Much Do You Smoke A Day?
How Would You Rate Your Smile
(worst) 1 2 3 4 5 6 7 8 9 10 (Best)
How Often Do You Brush?
How Often Do You Floss?
What Type Of Toothbrush Do You Use?
Are You Subject To Prolonged Bleeding?    
Do Your Gums Bleed While Flossing?    
Do You Avoid Brushing Any Part Of Your Mouth Because Of Pain? If Yes, Which Part Of Your Mouth?
DO YOU FEEL TWINGES OF PAIN WHEN YOUR TEETH COME INTO CONTACT WITH::
• Hot Foods or Liquids, i.e. Soup, Coffee, Tea etc...  
• Cold Foods or Liquids, i.e. Ice Cream, Cold Fruit, etc...
• Sweets, i.e. Candy, Fruit, Sweet Desserts, etc...
• Sours, i.e. Lemons, Limes, Grapefruit, etc...
Do You Feel Any Pain Around Any Of Your Teeth When Brushing?
Do You Chew On Only One Side Of Your Mouth? If Yes, Please Explain:
Do Your Gums Feel Tender Or Swollen?  
Do Your Jaws Ever Feel Tired?
Do You Usually Have Any Cavities?
Do You Lose Or Break Fillings?
Do You Clench Or Grind Your Jaws Whilst Sleeping Or During The Day?
Do You Wear Full Or Partial Dentures?
Do You Gag Easily?
Please describe the treatment you wish to have as best as you can. You can use ADA procedure codes or teeth numbers specified by your dentist. Also add anything you feel is important such as special circumstances surrounding your treatment or if you have certain time restrictions for completing your treatment:
Do you have any other medical conditions we should know about or be aware of that could effect your treatment? Please explain:
Please tell us what your expectations are and the results you are hoping to achieve from your dental treatment - Please explain:
Please attach any Image files such as x-rays, treatment plan(s) or contracts and clinical chart notes. (Please note images must be in JPEG format)
X-Ray Image: X-Ray Image 2:
Picture 1: Picture 2:
Picture 3: Picture 4:

Please Allow Upto 5 Minutes For This Form To Send, Depending On The Number Of Pictures Attached.

It should be understood that the e-Consult is NOT a substitution for a clinical examination or Xray. The opinions offered are purely based on a set of hypothetical scenarios or recollection of events as the quality of the images and quality of the limited information you provide at the time of submission. We endeavor to provide as accurate a treatment plan as possible but please be advised that in some cases treatment plans will need to be altered once an xray has been studied.

Submission Date/Time:
   
   
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