Fillings Preferences
Please Read the following before answering the next question:
*If you are seeking to restore your smile, we encourage our patients to bring close up, high quality pictures of their old smile before any dental problems.
1 is At this time cost of treatment will dictate what I choose , 5 is I'm seeking the best treatments available
1 is I only want treatments that are 100% covered by Insurance , 5 is I will pay more “Out of my pocket” for better dental care. Even if insurance does not over the cost.
1 is I'm mostly seeking cosmetic treatment , 5 is My priority is healthy treatments. Cosmetic treatments are of secondary importance to me
1 is Put me to sleep for all dental treatments , 5 is I prefer to try and manage my dental Apprehension
1 is I want to know step by step details during clinical treatments , 5 is After a doctor has gained my trust, I like to relax during dental treatments. I do not want Step by Step Details unless it’s really important
1 is I like to make all of my own decisions , 5 is If I find a trusted expert, I like to defer a doctor’s profession option
1 is I want the maximum safe amount of dental anes needed to assure I will not feel anything , 5 is I want very little to no dental anesthetic. If If feel something I will raise my hand
1 is Please provide prescription strength pain reliever , 5 is I don’t like taking prescription strength pain relievers. Please recommend an over the counter solution
1 is I don’t mind taking antibiotics. Offer me antibiotics even if there is a small chance for a post treatment infection, 5 is Only offer antibiotics when there is a higher statistical chance for infection or when Dr feels it's necessary
1 is I’am prone to dental infections , 5 is I heal quickly
1 is My work schedule is very important , 5 is My health is more important then my work schedule
1 is I talk a lot at work and can’t be numb during working hours. Use little or no anestheti , 5 is I don’t want to feel pain during dental visits. numb me, It's okay if I stay numb for several hours after dental treatments
1 is Age mature patients should not Investing time and money in high quality dental care. , 5 is Old or young, it does not matter. Dental health, fresh breath, comfort, and the ability to eat is very important at any age
1 is Older folks don’t need to look good , 5 is Looking good is a personal preference & the desire to look good is admiral at any age
1 is I’m a Perfectionist , 5 is I like to go with the flow
1 is It's appropriate to look well groomed, but I think society relies too much on physical appearance , 5 is Physical appearance is very important to me
1 is “I like to do my own research: I want to review all of the treatment details with the doctor. Then I will decide on treatment options, 5 is I prefer to spend the time with the goal to find a professional & then “trust the doctor to decide"
1 is I want whiter teeth , 5 is I want natural looking teeth to match my existing color
1 is I want a Hollywood White Smile , 5 is I’m seeking to improve my smile. I don’t want to spend time or money on a perfect smile
1 is Regarding dental restorations, ie Crowns and Veneers, I refer a monolithic look: i.e. Little to no yellow root stain or chewing edge grey transparency, 5 is Regarding dental restorations, i.e. Crowns and Veneers, I prefer teeth with numerous color variations and varying translucency
1 is Because back teeth are more difficult to see, I not seeking prefect cosmetic results. Please use life-like tooth colored dental fillings and Crowns, but lean toward the longer lasting materials, 5 is I want dental crowns and fillings on my back teeth that are aesthetically as close to perfect as possible. Even if its more expensive, takes longer, and may not last as long
Fillings Options
Orthodontic Q’s
Dark Grey Tooth Treatments
Front Teeth Wear & Dental Bonding Chipping
This Section MUST be signed in the office
To the best of my knowledge all of the preceding information is true and accurate.
Signature: _________________________________
Print Name: _________________________________
Date: ________________
We appreciate your time expressing your past experiences and personal preferences. Your efforts will afford our team to ability to focus on your specific preferences and ultimately provide you with the best dental experience.
If you are a New Patient
You can fill out your new patient paper work now
1. Patient Personal Information Form (Print, Fill Out & Fax or Email)
2. Medical Health History E-Form
3. Dental History E-Form
If you have had a Bad Dental Experience, we strongly recommend you review
Bad Dental Experience Patient communication E-form
Recommended Reading:
7-Steps Proven To Reduce Dental Fear & Anxiety
1. Relaxation Techniques To Stay Calm During Dental Treatments
2. Self Help Strategies to overcome Dental Pain & Fear
3. Top 25 Dental Fears & Our Solutions “Facing Your Fears”
For Those Seeking Exceptional Care, please fill out:
Personal Preferences Patient Communication E-Form
What Happens Next
It’s required that we keep your online information private and secure. Accordingly you will need to create and enter a 4-6 digit ID number on any E-form filled out on our site. Retain this 4-6-digit number as you will need to provide it to our scheduling coordinator. In turn, they will download your online information and save it to a new account hosted on our private secure server.
Your best option is to call our office in advance of your appointment date. This will allow extra time for Dr Landers to review the E-forms you took your time to fill out.
When you Call Please provide the Following E-form Information:
1. First & Last Name
2. The Names of E-Forms You Fill Out Online
3. The 4-6 Digit Number You Entered On The E-Forms.
We Will Use This ID Number To Attach Your E-Forms “Privately” To Your New Account At Our Office
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