Medical History E-Form - Advanced Cosmetic Dentistry

Cosmetic Questionnaire E-Form

If we are to make recommendations centered on your goals and desires, your help is essential. Please take a few minutes to fill out this form as complete as you can. We look forward to working with you in maintaining your dental health.
Your smile enhancement goals (Check all that apply)

Complete smile makeover Smile enhancement (not a complete makeover) Minimally invasive treatment options Health first treatment Natural looking smile Whiter teeth Treatments to achieve a perfect looking smile Hollywood style smile makeover Interested in only one specific type of treatment Treatment focused only on a few teeth Treatment for pain or discomfort only Fast dental treatment options (2-8 Weeks) Same day care for a particular dental problem
Optional - Is there a special occasion date? What is your time frame or goal date to complete treatment?
How did you find us? (Check all that apply)

Personal recommendation Looked up dentists near me Another doctor’s office Professional dental organizations American Academy of Cosmetic Dentistry (AACD) Reviews -Yelp Reviews -Google Youtube (videos) Our before & after images Internet search
Optional -If you found us on an internet search, please include the key words searched:
How did you prepare for your cosmetic consultation? (Check all that apply)

I do a lot of online research I read books about dentistry i.e. Billion Dollar Smile or other guides I have consulted with several other dentists I have had many dental treatments over the years. At this point, I consider myself proficient in dentistry I have a personal friend or family member who is a dentist or lab technician who advises me. I worked in the dental profession or currently work in the dental profession None of the above
What do you like most about our website (Check two)

Before and After pictures Dr Landers' training and credentials Finding one dentist for all your needs Specialized treatments offered Written patient reviews Real life stories (patient videos) Personalized communication forms Beneficial topics & content on our website Not sure yet
Regarding causes of your dental problems (Check all that apply)

My enamel is soft and I seem to get a lot of cavities I have problems with my saliva I need to be better with my home care. I don’t brush or floss often enough I rarely brush afterward sugary foods & snacks I don’t brush my teeth before I go to bed I have medical conditions which cause dental problems I am inherently disposed / my dental problems are genetic I take medications that cause dental problems My parents did not take me to the dentist I’ve always had poor quality dental care I have dry mouth I have a uneven, unbalanced - bad bite I grind my teeth Most of my problems are result of bad dental treatments My problems were caused by another Dentist I have more problems then the average person but I have no idea why I think my dental problems are normal History of a past trauma None of the above
If from trauma, describe the trauma and provide the dates:
Fillings Preferences

Please Read these 3 Filling Facts before answering the following question:
1. Silver Metal fillings are stronger, cause less post treatment sensitivity, less expensive, and last longer then White Plastic fillings.
2. Porcelain fillings (dental porcelain onlays) are made of a strong tooth colored material that lasts longer then metal, or white plastic fillings. The benefit of using a porcelain filling increases, as the filling gets larger.
3. The down side of a porcelain filling is that they are the most expensive type of dental filling.
Metal fillings vs White plastic fillings vs White porcelain fillings: (Check all that apply)

I do not want any metal fillings. Even if they are stronger, last longer, and statistically cause less post treatment sensitivity then white plastic fillings If a metal filling is better, I don’t mind a metal filling on a tooth or a location that is difficult to see Cost and/or insurance coverage are not my main concern. Nonetheless, I would like a cost benefit of each type of filling explained to me Metal, white plastic, or porcelain, it does not matter to me. I would like the filling material that lasts the longest, causes the least amount of post treatment sensitivity, and best protects my tooth from root canals or breakage Cost is not my main concern, health & protecting my tooth are most important to me. I would like a quote for the best dental material for each specific situation I am not concerned about how long a filling will last or what color it is. I would simply like the least expensive filling options. I would like the filling my dental insurance will most likely cover I have a general dentist who handles my fillings I’m not interested in changing any fillings at this time Non of the above
Your smile design expectations (Check all that apply)

I am not trying to have 100% perfect results I’m a perfectionist; I refuse to accept any standard short of perfection I want as close to 100% perfect results as is be humanly possible I have high expectations, but I understand that achieving 100% perfect results may not be possible I just want smile enhancement. I am seeking an improved smile not a perfect smile I am seeking optimal results based on my current condition I am not worried about how my smile looks, as long as I am healthy and it’s comfortable to eat None of the above
What best describes the specific type of smile you are seeking: (Check all that apply)

I want the greatest level of regularity between teeth shape, size and alignment I want the maximum level of whiteness/brightness I want an amazingly beautiful “Hollywood Smile” & don’t mind if some people don’t believe it looks real I want a beautiful smile that is as white & bright as possible with out looking too fake. My goal is that most people think it looks real I want a “beautiful & a little whiter smile, but not perfect. I’m going for the more subtle look” I want a natural looking smile that looks clean and healthy. I’m not apposed to slightly whiter teeth, but I am seeking a more natural look I don’t want whiter teeth. I just want dental restorations to match my existing teeth I am not worried about all of the imperfections that I see close up, but others mostly don’t notice. The smile enhancements perceivable by others from conversational distance are most important to me I am not interested in cosmetic dentistry, as long as I am healthy and it’s comfortable to eat I’m seeking to restore the look of my old smile. I will bring close-up pictures of my old smile I have pictures of another person's smile as an example of what I like None of the above
If you have pictures of another person’s smile. (Check all that apply) If you don’t have pictures, skip to the next question.

I only want a doctor who is skilled enough to give me the exact smile in my pictures I have brought pictures of another person’s smile as an example of what I like. I understand these images are of a smile that is anatomically different then my own smile. Considering the latter, I understand that some of the anatomical details might not be achievable I brought smile images of other people so that I could point out what I like. Please explain how my existing pre-treatment condition will affect Dr Landers' ability to achieve my goals and desires I know that no doctor or professional for that matter can promise perfect results. I am simply looking for a doctor who will give me the best chance of having my own personal best smile I don’t have pictures of another person
*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.
Smile design IQ vs. Patient-Doctor communication (Check all that apply)

I know exactly what I want and I am seeking a doctor who can confidently delivery my desired results I can’t explain exactly what I want; I’m hoping to find a doctor who can help me to explain what I want I am interested in learning about how my current condition will affect the final results of my smile makeover None of the above
Treatment predictability (Check all that apply)

I understand that in order to achieve excellence, I will need to be flexible in the event my needs change over the course of treatments. I understand that additional time and visits may be needed If I am paying for high quality care, I strongly believe that the treatment results should be predictable for each and every step of treatment. I don’t have extra time and I don’t feel I should have to return to correct problems that were not predicted at the beginning of treatment If treatment is not done right the first time, I will stop all dental treatments and will typically stop going to the dentist who caused the problem None of the above
Your past experiences with smile design (Check all that apply)

I was shown a smile design on a computer screen, but I was unhappy with the final result. My final smile did not look like the computer animation The Dentist “farmed out” my smile design to a dental lab technician I have never met. My teeth models were sent in the mail and the dental tab returned wax version of my smile. The dentist reviewed the wax version of my new smile with me, but I ended up unhappy with the final results. My new smile did not look like my temps or the lab wax-up The dentist took a digital scan of my teeth and used smile design software to create my smile, but I was unhappy with the final new smile. It did not look like the computer animation The dentist did not do smile design at all and I was unhappy with my final new smile None of the above
List of possible dental problems

Check off any that apply to you
Orthodontics:

Uneven Teeth Length-10 Long Teeth Over eruption Short Teeth Under Eruption Misaligned Teeth Crooked Teeth Crowded Teeth Overlapping Teeth Moved Back After Braces Moved Back After Invisalign Ectopic Eruption Teeth Gaps Spaces Between Teeth -10 Diastema Closure Black Triangles Between Teeth Interdental Papillae Missing Midline Not Centered Midline Canted /Angled Tooth Axis Of Inclination Off Small Teeth Big Teeth Bad Tooth Shape /Proportion Overbite Under Bite Deep Bite Cross Bite Edge To Edge Bite Overjet Underjet Open Bite Tongue Trust /Tongue Posture Teeth Tipped Forward /Buck Teeth Bite Collapse (Virtical Closure) Missing Teeth in Back Wisdom Teeth Vs. Teeth Shifting Tooth Keep Moving Did Not Wear Retainer Retainer Broke Teeth Shifted Root Resorption (Short Roots) Internal Root Resorption External Root Resorption *Molar -Uprighting Tipped Tooth *Move Tooth to Create Space for Implant Malaligned Upper Or Lower Jaws Upper Jaw Bone Too Far Back Or Forward Upper Jaw Tipped Up in Front Upper Jaw Slanted –Higher on Left or right Crooked Smile Lower Jaw Forward Lower Jaw Back Lower Jaw shifted too far Right or left Narrow Arch Form Dark Buccal Corridor Upper Arch too wide Mouth Breathing Braces take too long
Implant:

Missing Teeth Missing Front Tooth Missing Back Tooth Loose Teeth, Tooth Mobility Loose Sore Denture Congenitally Missing Later Incisors Retained Baby Tooth Maryland Bridge (Resin Bonded) Keeps Falling Out Roots Too close for Dental Implant placement Bone Loss Boney Defects Indentations In Gums & Jawbone Bony Dehisence & Fenestration under Gums Osteoporosis Not Enough Bone For Implant Infected Dental Implants Peri-implantitis Implant Screw Loose Loose Dental Implant Implant Rejection Failure Implant Tooth Looks Bad Fake Implant Shows Through Grey Crown Dark Implant Crowns Implants Treatment Takes too Long Fast Implant Treatments Same Day Implant Teeth
Cosmetic Restorative:

Chipped Tooth -110 Cracked Teeth Teeth Lines/Cracks-10 Cracked Root Holes In Teeth-10 Teeth Pits From Acid Erosion Broken Tooth -50 Broken /loose Dental Crown Broken Porcelain Veneer Broken /loose Dental Bridge Broken /loose Filling Tooth Cavities /Rotten Teeth -110 Worn Teeth Old Teeth Weak Tooth Structure Leaky Dental Work Poor Tooth Quality & Quantity Dental Crown Keeps Fell out Dental Bridge Keeps Fell out Porcelain Veneer Fell out Filling Fell Out Replace Bad Fake Dentistry Fake bad Color Match Bad Fake Metal Bridges Bad Fake Crowns Bad Fake Porcelain Veneers Reverse Smile Teeth Edge Line Smile teeth Edge Line Not level with Face Smile teeth Edge Line not level with lips Smile Teeth Edge Line Worn Flat Low Lip Cant See My Teeth High Lip Too Much Gums Small Teeth Smile-10 Peg Laterals Missing Laterals Canine Substitution Root Surface Cavity /Lesion Root Abfraction Dark Fillings Silver Fillings Mercury Sensitivity Black Line At Gums Dead Grey Tooth Root Resorption Bite Closure & Collapse Chipping, Breakage, Wear & Movement Due To: Day Time Habits Chipping, Breakage, Wear & Movement (Bite Changes) Due To: Night Time Grinding Or Night Time Oral Appliance (Sleep Apnea Appliance) Acidic Breakdown Of Tooth Structure: Bulimia, GERD, Acidic Diet
Surgical

Bone Loss Dark Gums Bony Defect Missing Interdental Papillae Small Teeth Smile-10 Gummy Smile Uneven Gum Line Attached Gum Thin Gum Recession from Tissue Pull Receding Gums Root Exposure Crown Margin Shows Sensitive Tooth Root Long Front Teeth Gum Defect Cavity Below Gums Broken Tooth at or Below Gums Bony Ridge Exostosis & Tori Failing Root Canal Bone Infection At Tip Of Root Bone Cyst Pimple On Gums Bleeding Gums Periodontitis Loose Mobile Teeth Trench Mouth Black Triangle Wisdom Teeth Pain Swelling Impacted Tooth Tooth Pain & Sinuses
Color/ Enamel Defects

Stained Teeth Discolored Teeth Yellow Teeth Grey Teeth Food Stains Coffee Or Tea Stains Dead Tooth Dead Tooth Nerve Enamel Defects Antibiotic Staining White Spots On Teeth Hypo Calcification Hyper Calcification Amelogenesis imperfecta Fluorosis Thin Worn Enamel Thin Chipping Sharp Tooth Edge Fix Old Bad Fake Dentistry Old Yellow Bonding Poor tooth Color Match Metal Post Front Tooth Tooth Cavities /Rotten Teeth Spaces Gaps Black Triangles Yellow Crowns Dark Grey Crowns Dental Plaque /Calculus Whiten Veneers Exposed Yellow Tooth Roots
TMJ/ OcclusionJaw joint (TMJ) pain

Bad Bite Impingement of Lower Teeth & jaw behind upper teeth. Occlusal (Tooth to tooth) Trauma Avoidance pattern/ Functional shift Bite Doesn’t Feel Normal Pain soreness and Top & bottom Root Canal Gone Bad Apicoectomy Didn’t Work Migraines Headaches Facial Muscle Pain Clenching Grinding Jaw pain After New Dental Work Pain or tenderness in your face, jaw joint area, neck, shoulders, and around ear. Bite Collapsed From Degenerative Jaw Joint Lack Of Canine/Lateral Guidance Sleep Apnea And Snoring
Psychological

The Aging Smile Look Younger Smile Makeovers Position Or Shape Of Your Teeth/Crowns Treatment Took Too Long Bad Dental Experience Second Opinion Dental Anxiety & Phobia Old Outdated Dentistry Healthy Treatments Dental Phobias Cost Of Dental Treatment Insurance Decreased Or Non Payment Hollywood White Minimally Invasive Health First Dentistry
Emergency Problems

Broken Sharp Tooth Oral Cancer Canker Sores Oral Herpes Amthus Ulcers Burning Mouth/Tongue Dry Mouth Syndrome Bleeding Gums Swollen Gums Abscess Gum -70 Abscessed Tooth Gum Disease /Periodontal Disease Tooth Sensitivity Tooth Pain Food Impaction Tooth Aches Thumb Sucking Parafunction Day/night Braces Bracket Loose Broken Lost Invisalign Tray Retainer Wire Broke Wire Pocking
Causes Of Problems

Dry Mouth Sleep Apnea Daytime Habits Nighttime Habits Poor Oral Hygiene
Denture

Lower Denture Problems –RS Loose Dentures Broken Denture Broken Lost Denture Tooth Broke Denture Clasp Or Attachment Denture Pain When Eating Denture moves when speaking
Top 10 Hidden Dangers You Will Encounter Completing Cosmetic Restorative Dentistry

1. Weak Tooth (Ferrule)

2. Black Tooth

3. Lack Of Canine/Lateral Guidance

4. Bone Defects: Dehisence & Fenestration

5. Occlusal Trauma Vs Tooth Mobility

6. Cracked Tooth

7. Insurance Non Payment

8. Malocclusions: Class III Deep Bite, Open Bite, Bite Collapse, Degenerative Jaw Joint

9. Parafunction

10. TMD

For Dental Problems Related To Dental Emergencies, Please See Our Dental Emergency Self Help” Section On This Site Or Call Our Office.

Front Page Emergency Topics * Each Topic Will Have To Be Outlined Vs. Problems 2017

#1 Knocked Out Or Loose Tooth

1. Intro Knocked Out Or Forced Loose Tooth.Doc

2. Knocked Completely Out.Doc

3. Knocked Inward Into The Tooth Socket.Doc

4. Knocked Loose & Still In Position.Doc

5. Knocked Out Of Position.Doc

6. Loose Children's Baby Teeth.Doc

#2 Broken-Chipped Tooth And Or Lost Filling

#3 Tooth Ache

#4 Injuries Soft Tissues Of Mouth & Jaw

#5 Common Mouth Sores

#6 TMJ Or Grinding Pain Or Migraine Pain

#7 Swollen Infected Face, Gums, Or Wisdom Teeth

#8 Loose Permanent Crowns Or Temporaries

#9 Emergencies After Surgical Procedures

#10 Emergencies After Routine Dental Procedures
List your dental problems. (While additional detail is always helpful, this section is optional)
List the dental procedures you are seeking to correct you dental problems:

Please check all procedures and treatments below that you may consider for treatment. This section is highly recommended. If you don’t have an opinion or if you're not sure, leave it blank. Do your best, you can always change your mind later.

	1st Choice	2nd Choice	3rd Choice	Maybe (I want more info)	I don't want this	Need More Info to Decide (Please share more info about this service)
Porcelain Veneers
Dental Bonding
Porcelain Crowns
Dark Grey Dead Tooth Treatment
Tooth Supported Dental Bridge (Front teeth)
Tooth Supported Dental Bridge (Back teeth)
Dental Implant to Replace Old Bridge
Full Mouth Reconstruction
Smile Tune Up (For People Seeking Minor Improvements Only)
Gummy Smile Treatments
Level Uneven Gum Line
Gum Graft & Root Coverage
Laser Gum Treatments
Invisalign
Clear Teeth Aligners (4-8 Wks)
Clear Braces
Fast Surgical Orthodontics
Metal Braces
Save Teeth with Gum Surgery & Restorative Treatments
Extract Teeth & Replace with Dental Implants
Bone Grafts for Dental Implants
Dental Implants Front Teeth
Dental Implants Back Teeth
Implant Bridge Front Teeth
Implant Bridge Back Teeth
Full Upper Or Lower Implants
Teeth In A Day (Implants Bridges)
All On 4 or 6 Implant Bridges
Computer Guided 3-D Implant Surgery
Implant Retained Denture
Denture with No Implants
In office Laser Teeth Whitening
Professional Take Home Whitening
Whitening for Life
TMJ Joint & Bite Therapy
Mouth Guards /Daytime Habit Appliances
Sleep Apnea Appliance
White Fillings
Metal Fillings
No Needle Drill Less Fillings
All Porcelain Crowns Back Teeth
Porcelain Fused to Metal Crowns
All Porcelain Onlays
Routine Dental Cleaning
Fresh Breath Treatment
Computerized Root Canals
Wisdom Teeth Extractions

*Optional - In your own words, share how your ideal smile would look. Please include location of problem.
Patient preferences regarding tooth shaping & preparation (Check all that apply)

I would like to be offered cosmetic treatment options that do not involve or require any tooth removal. I understand that my request to not allow tooth removal could affect the final outcome of my treatment (i.e. less optimal cosmetic results) Please offer options, which allow for minimal tooth removal. I understand that my request to not allow tooth optimal removal may affect the final outcome of my treatment (i.e. less optimal cosmetic results) I really would like an amazing smile. I agree to remove the amount of tooth structure that is required and suggested based on dental industry standards. I understand that Dr Kevin Landers implements all modern day techniques to accurately shape and prepare my teeth for dental restorations. Including fabrication and use of a reduction matrix If tooth structure needs to be removed to improve aesthetics, I agree and trust Dr Landers' judgment. In other words, I want Dr Landers to shape my teeth as needed so I can have the most predictable cosmetic results Clear teeth aligners move teeth fast (4-6 weeks) and decrease the need to remove tooth structure. If the latter is true, I prefer to move my teeth before they are shaped for dental veneers or crowns None of the above
Patient preferences regarding how teeth, which are tipped forward affect the final look of porcelain veneers. (If your teeth are not tipped forward skip this question)

I don’t mind that my teeth or if the final Veneers are tipped forward I don’t want my veneers to be tipped forward. I don’t like the “buck teeth” look I don’t want veneers which are too bulky looking If I choose to do multiple veneers, I don’t want an uneven color match. I would like all of the dental veneers to be similar in color and brightness My teeth are tipped forward, I don’t want orthodontic treatment to move my teeth, I don’t want my tooth structure removed, and I don’t want my final veneers tipped forward None of the above
Treatment options for patient with teeth that are tipped forward: (If your teeth are not tipped forward skip this question). If my goal is to end up with straight looking teeth which line up in a ideal cosmetic arch form and look good from the side (profile): If my tooth or teeth are tipped forward:

I would like to tip my veneers or crowns forward Please remove the portion of the tooth, which is tipped forward, and then cover it with the veneer or crown. I want straight looking teeth after treatment Clear teeth aligners move teeth fast (4-6 weeks) and decrease the need to remove tooth structure for teeth tat are tipped forward. If the later is true, I prefer to move my teeth before they are shaped for dental veneers or crowns
What’s most important to you (Choose one)

Cost Time Health Optimal Cosmetic Results

	1	2	3	4	5
At this time cost of treatment will dictate what I choose						I'm seeking the best treatments available

	1	2	3	4	5
I only want treatments that are 100% covered by Insurance						I will pay more “Out of my pocket” for better dental care. Even if insurance does not cover the cost

	1	2	3	4	5
I'm mostly seeking cosmetic treatment						My priority is healthy treatments. Cosmetic treatments are of secondary importance to me

	1	2	3	4	5
Put me to sleep for all dental treatments						I prefer to try and manage my dental Apprehension

	1	2	3	4	5
I want to know step by step details during clinical treatments						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	2	3	4	5
I like to make all of my own decisions						If I find a trusted expert, I like to defer a doctor’s professional option

	1	2	3	4	5
I want the maximum safe amount of dental anesthetic needed to assure I will not feel anything						I want very little to no dental anesthetic. If I feel something I will raise my hand

	1	2	3	4	5
Please provide prescription strength pain reliever						I don’t like taking prescription strength pain relievers. Please recommend an over the counter solution

	1	2	3	4	5
I don’t mind taking antibiotics. Offer me antibiotics even if there is a small chance for a post treatment infection						Only offer antibiotics when there is a higher statistical chance for infection or when Dr feels it's necessary

	1	2	3	4	5
I’am prone to dental infections						I heal quickly

	1	2	3	4	5
My work schedule is very important						My health is more important then my work schedule

	1	2	3	4	5
I talk a lot at work and can’t be numb during working hours. Use little or no anesthetic						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	2	3	4	5
Age mature patients should not Investing time and money in high quality dental care.						Old or young, it does not matter. Dental health, fresh breath, comfort, and the ability to eat is very important at any age

	1	2	3	4	5
Older folks don’t need to look good						Looking good is a personal preference & the desire to look good is admiral at any age

	1	2	3	4	5
I’m a Perfectionist						I like to go with the flow

	1	2	3	4	5
It's appropriate to look well groomed, but I think society relies too much on physical appearance						Physical appearance is very important to me

	1	2	3	4	5
“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						I prefer to spend the time with the goal to find a professional & then “trust the doctor to decide"

	1	2	3	4	5
I want whiter teeth						I want natural looking teeth to match my existing color

	1	2	3	4	5
I want a Hollywood White Smile						I’m seeking to improve my smile. I don’t want to spend time or money on a perfect smile

	1	2	3	4	5
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						Regarding dental restorations, i.e. Crowns and Veneers, I prefer teeth with numerous color variations and varying translucency

	1	2	3	4	5
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						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

Question's vs Insurance (Check the statement that best fits)

It’s my understanding that my dental insurance covers 100% for most all dental procedures I don’t know the amount if any that my dental insurance covers please estimate for me I don’t know the amount if any that my dental insurance covers. please help me to maximize and estimate my benefits I would like to have the highest quality care and the longest lasting treatment. Please give me a cost estimate to maximize my insurance coverage but please do not make decisions based on insurance limitations At this time of my life, I am insurance dependent. I do not want any dental care which is not covered by my dental insurance even if my insurance only covers outdated materials or old techniques I have great insurance and I think it will cover most of treatment costs None of the above
Q’s vs Time (Check the statement that best fits)

I am willing to wait; it waiting gives me the best odds to achieve optimal healthy results I want all treatment completed before X date I want my most beautiful smile, but I want all treatment completed by date I am very busy. If treatment takes too long, then I would rather not complete that recommended treatment
Treatment Specific Questions

The following questions are optional. Only answer questions if it relates to the specific treatments you are seeking.
Surgery preferences (Check all that apply)

I want to avoid any type of surgery Will agree if it has a health related benefit Will agree if there is a significant cosmetic improvement Will agree if it’s not too expensive None of the above
Night time grinding (Check all that apply)

I’ve been told that I grind my teeth by another dentist I am 100% certain I grind my teeth because I have caught myself and/or my spouse has observed me grinding at night I often wake up with sore jaw muscles I often have sore jaw muscles during the day I don’t have a grinding appliance I have an over the counter grinding appliance I don’t like wear a grinding appliance None of the above
Fillings Options
Metal Fillings

I do not want any metal fillings I don’t mind a dental filling positioned on a tooth or area where it is not commonly visible Does not matter if it’s metal or if it’s a white tooth colored restoration. I want the type that lasts the longest and best protects my tooth from root canals or breakage
Orthodontic Q’s
What best describes your personal preference regarding wearing braces for tooth movement.

I will wear braces as long as 2-3 years if needed I will wear braces for a short period of time if there are no other options I will wear braces, but only as a last result. I am mostly interested in clear teeth aligners or Invisalign I will not wear braces. This simply is not an option I would choose None of the above
If there is a benefit of porcelain braces I will only wear them for:

2-months 4-months 6-months 12-months I want to try clear teeth aligners first, but agree to switch to porcelain braces for a short period of time if needed I will not wear porcelain braces None of the above
My teeth moved after braces because (Check all that apply)

I received poor quality treatment I did not wear my retainer My tooth to tooth bite forces never felt right after treatment I have a tongue thrust habit or posture my tongue forward between my teeth I’m a mouth breather None of the above
Dark Grey Tooth Treatments
If you have a dark grey tooth and want treatment (Check all that you believe to be true)

Natural looking results are 100% predictable if you choose the right dentist Teeth can be dark for many different reasons. The type of problem will affect the predictability of treatment If the tooth root is black under my gums, it will create a shadow above my tooth. The type of porcelain chosen for the final crown may not change this shadow above my tooth Matching a porcelain crown to a adjacent natural teeth requires extra dental visits Matching natural teeth requires that the dentist hire and excellent dental lab which is commonly more expensive None of the above
Thicker dental porcelain is required to mask a dark tooth (Check off your preference)

I’m only seeking an improved smile. I don’t expect that all of the dark color will be masked or blocked with the new crown. I don’t want to remove additional tooth structure in addition to what is normally required during Porcelain Crown preparation. Even if it means I will end up improving cosmetic results, I do not want to weaken my tooth in any way I really want the best possibility of achieving perfect results, even if it means removing additional tooth structure. I will agree to orthodontic tipping of my tooth backwards with clear teeth aligners if needed I don’t want to remove more tooth structure but am willing to except a slightly thicker looking or bulky crown to mask the dark colored tooth None of the above
Front Teeth Wear & Dental Bonding Chipping
The wear on my front teeth is from: (Check all that apply)

Grinding at night Subconscious daytime habits Another dentist shortened or shaved them down Trauma I don’t know
Would you like help regarding financing your procedure?

Yes No
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: ________________
Summary
Check to indicate the E-forms you filled out on our website:

Patient Personal Information Form (Faxed to: 312 263-7013) Dental Insurance E-Form (Faxed to: 312 263-7013) Medical Health History E-Form Dental Health History E-Form Cyber Consult *Send X-Rays & Images Personal Preferences Patient Communication E-Form Pain Management Patient Communication E-Form Bad Dental Experience Patient Communication E-Form Patient Satisfaction Survey E-Form
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:

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

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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:

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Contact Us Today! 312-263-7823
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Cosmetic Questionnaire E-Form

List of possible dental problems

Treatment Specific Questions

Summary