Personal Preferences E-Form - Advanced Cosmetic Dentistry

Personal Preferences Patient Communication E-Form

.Please take your time and fill out as much of this form as possible. Due to HIPPA Privacy Laws, some sections cannot be filled out online and can only be completed in the office. If you have questions we'll be glad to help. We look forward to working with you.
We understand that each and every patient has his or her own unique needs and desires.

For this reason we encourage our patients to kindly communicate their preferences.
Take baby steps or get it done ASAP? (Check all that apply)

As a new patient, if I accept treatment, I would like to take baby steps beginning with simply dentistry first. Then as I get more comfortable with Dr Landers, I will decide on a pace, which best matches my desire to finish treatments I want optimal and safe results but prefer to finish treatment quickly, and efficiently. I want to complete as many treatments per visit as is safe I’m in not rush to start. I would like to have a treatment-planning visit first. Then I will review my treatment options and decide I’m not in a rush to finish treatments. I am seeking optimally predictable treatments even if it takes a longer period of time to complete. I don’t mind waiting a longer in between visits to allow for optimal healing time before the next treatment step is started I am seeking same day care; I prefer to start on my first visit if possible I currently have an urgent or painful dental problem and I need treatment as soon as possible None of the above
(Optional) Describe your urgent or painful dental problem:
Your comfort in a dental chair (check all that apply)

I don’t feel good if the dental chair is reclined back too far Please let me know before reclining me back in a dental chair I have Back or neck pain while sitting in the dental chair for too long Would you like to try dental chair neck & back support pillow cushions None of the above
Past experiences with dental anesthetics (check all that apply)

Have you ever had treatment and thought “My mouth wasn’t numb enough during a procedure” Does it take you longer to get you numb Does the anesthetic wear off quickly Do you consider your teeth and mouth to be more sensitive than the average person Do you feel you need more anesthetic than the average person I don’t want to see the dental needle Do you get numb really easy and feel that you don’t need much anesthetic None of the above
Numbing Preference (Check one box that best describes your goals)

I do not like the feeling of being numb and dental pain does not bother me. I prefer little or no dental anesthetic The dental anesthetic can't last long after treatment because I can't be numb at work I prefer that Dr Landers take the time needed, and request that he uses the maximum safe amount of anesthetic necessary to ensure my comfort I have not experienced pain during a dental procedure. I prefer that Dr Landers decide how much time is required and how much dental anesthetic is needed for my specific procedure None of the above
Numbing once or allow multiple sessions (Check all that apply)

If I am already mostly numb from the first shot, and my specific dental treatment typically requires more anesthetic, please give me as much anesthetic as the doctor recommends I don't care if I don't feel it, I do not want multiple shots. Even if the doctor recommends it I prefer as little anesthetic as possible. If I feel numb from the first shot, I would like the doctor to start the procedure. If I feel something during treatment I will let him know. After which time, I will agree to a second or third numbing session None of the above
During dental injections (Check all that apply)

Injections don't bother me at all I'm a little nervous but I feel that my level of concern is normal I am afraid but I have heard Dr Landers has special techniques for Painless dental injections I am very afraid of dental injections None of the above
During dental injections I have experienced (Check all that apply)

A temporary (2-5 minute) increased heart rate or a flushed feeling Anxiety, restless feeling, shaking, or feeling like you might pass out I have passed out after dental injections Nausea, upset stomach I do not like the unpleasant taste in your mouth during or after dental numbing procedures None of the above
Problems Experienced After Dental Injections (Check all that apply)

Allergic reaction to the dental anesthetic Difficulty opening your jaw for a period of time after the dental visit I feel like the dentist gave me too much and numbness lasted way too long I experienced Nerve damage from a dental injection, Note: Nerve damage is very rare in a regional injection, according to the "American Society of Regional Anesthesia and Pain Medicine (ASRA)" Bruising (I bruise easily) Seizure: if you have a condition characterized by recurrent, unprovoked seizures (Epilepsy) Please include this in your medical history and let Dr Landers know before dental numbing None of the above
Preferences regarding prescription strength pain medication (Check all that apply)

I do not want any prescription strength pain relievers I probably will take an over the counter pain relievers but please write a prescription just in case I need it I simply want to avoid any after treatment discomfort, please give me a strong pain reliever I would like prescription strength pain relievers None of the above
Please list what you have used in the past that works well for you.
Preferences regarding prescriptions in general (Check all that apply)

I don't mind taking antibiotics. I would like to trust the doctor's recommendations regarding when I should take antibiotics I understand that many dental procedures involve a low percentage risk of post treatment infections. I prefer to take antibiotics for procedures, which have a higher percentage chance of post treatment infection I want to take antibiotics for every dental procedure, which involves even a small percentage risk of post treatment infections When applicable, if steroids reduce swelling and side effects, I would like a prescription please I prefer to use nitrous gas for all dental procedures. I understand there is an additional charge None of the Above
If you have a sensitive gag reflex list dental procedures that trigger your gag reflex

Dental impressions Cotton under your tongue Excess water or saliva in the back of my mouth Dental cleanings Dental work on the back teeth Wearing dental appliances like retainers, night guards, or whitening trays None of the above
List additional events which have caused you to gag during dental treatments:
Regarding treatment recommendations (Check all that apply)

I have had several doctors during the past five years. At this point, no dentist has convinced me that they have the skill or ability to fix my dental problems In the recent past, I have had multiple problems with dentists; I don't trust dentists in general. At this point, I know enough to seek out second opinions I am a researcher and I have a lot of dental experience. I read a lot, and double check on the Internet to help me make dental decisions I have a friend or family member who is a dentist or dental lab technician. I always double check with him or her to make sure the correct treatment is offered for my dental problem 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 viewpoint regarding treatment presentations (Check all that apply)

When a dentist offers low cost dentistry, it's insulting, because he's assuming patients don't have enough to pay for quality care treatments The dentist should not offer patients the best treatments options or try to up-sell The dentist should know what patients want and ask patients their budget before presenting treatments options Patients should communicate their financial concerns before their consultation, so the dentist can customize a specific plan for their budget I don't feel comfortable talking with the doctor about finances. I feel it's more appropriate to speak to the staff member who routinely handles insurance and personal financing Doctors should not be thinking about patient's finances at all during treatment presentations. They should be focused on explaining quality care treatments, alternative treatments, and benefits of each The dentist should offer multiple treatment choices in a Good/Better/Best order. Followed by a cost/benefit for each, then let patients choose what they want The Dentist should offer best treatments first. This should be based on what he would choose for himself. Then follow up with alternative treatment options along with the cost/benefit for each None of the above
Finish all needed treatments now or plan to finish it in the future over a period of time (Check all that apply)

I would like all of my dental problems fixed ASAP. I am also interested in finishing all preventative treatments at the same time as dental problems. I am seeking the highest quality care and I would like it finish as soon as is optimally safe I would like to spread the cost of my treatments over an extended period of time. I would like to plan my treatments in a priority first order. Please fix the most urgent dental problems first. Then give me a plan remaining treatments so that I can budget to finish these in the future I would like all treatments for my dental problems completed in a manner that is most efficient. Please group treatments together so I can finish all treatments in the least amount of visits If I am numb in an area of my mouth, I would like to finish all treatments in that area None of the bove
Check all that describe of your monetary goals when it comes to dental treatment

Cost is not my main concern. Only offer me the best available treatment options without regard to monetary concerns or price While cost is not my main concern, I would like to weigh all of my treatments options verse treatment costs I would like to consider cost & the related benefit of all treatment options. Then I will decide which treatments I will choose. I'm seeking quality care at far price I'm seeking modestly priced dental treatments with the goal to get the best care within my budget I would like to find out if I qualify for financing At this time, I am only seeking a "quick fix" - least expensive temporary patch. I will return in the future for definitive care Please only present treatments that are 100% covered by my insurance I do not want any expensive treatment options presented
Your monetary goals vs Your treatment goals (Check all that apply)

I'm seeking to invest in treatments that offer me the best value. I'm not interested in adding additional costs to fix the fine details that most people will not notice at conversational distance I am a perfectionist; I've don't a lot of research and I will undoubtedly notice every little detail. Given my current condition, my goal is to fix as many of the small details as possible. I would like an estimate to achieve my goals I do not want preventative care. Only offer treatments for painful or symptomatic dental problems I would like to hear all of my options. Offer me the best options first, followed by alternative treatment options. Then I will decide None of the above
If you don’t have dental insurance, please skip the next 2 questions.
What type of insurance do you have: (Check all that apply)

HMO - The least expensive kind of dental coverage will only reimburse dentists in network who agree to fee limitations and procedure restrictions PPO - Has a preferred network of dental providers who have agreed to fee limitations and procedure restrictions, but you can still get some coverage if you go to an out-of-network Dentist Dental indemnity plans- allow you to choose any dentist you want
Dental insurance vs Dental care (Check all that apply)

I have really good dental insurance and it covers 100% all dental procedures I don't know the amount if any that my dental insurance will cover for dental services. Please help me to maximize my benefits Please present optimal treatments based on what I need and want and not based on fee restrictions and limitations as set by my insurance company At this time of my life, I need to make treatment decisions based on what my insurance will pay for
Cost vs Treatment results (Check all that apply)

I will pay for as many procedures as necessary to give me the best possible results I don't care how long it takes I want the best possible results I want to pay for only the procedures, which provide the greatest improvement. I am not interested in optimal treatments which are offered to correct the small cosmetic details especially if there is an additional cost Please plan my treatments so that I get the best possible treatment results that fit my budget and explain the cost benefit of all treatments None of the above
Wish to stay informed during clinical treatment (Check all that apply)

Do you tend to predict which treatments are going to hurt Do you want to maintain as much control over dental treatments as possible Do you feel the need to see what's going on during clinical treatment Do you prefer to hold a hand mirror and periodically check what's going on during clinical treatments Do you feel a need to take photos of your mouth during stages of clinical dental treatments Do you like when the dentist explains most treatment steps as he proceeds through clinical treatment Do you prefer that the dentist not explain or share details of each step of clinical treatment Do you dislike seeing images of your dental problems or you teeth problems I prefer to relax during treatments. I don't need to know about every clinical step during treatment. Please review the details only when it's important. None of the above
Regarding Causes of your dental problems (Check all that apply)

I have weak enamel that chips easily I have acidic tooth erosion I experienced vomiting over a stretch of time. I have dry mouth I have problems with my saliva I often drink Coke Products I rarely brush afterward sugary foods & snacks I don't brush or floss often enough I don't brush my teeth before I do to bed I have medical conditions which cause my dental problems I am inherently disposed / my dental problems are Genetic I don't have healthy bone I don't have healthy gums It takes me longer to heal I take medications that cause dental problems I have a uneven, unbalanced - bad bite I grind my teeth I don't go to the dentist for routine check ups My parents did not take me to the dentist I've have always had poor quality dental care Most of my problems are result of bad dental treatments Most of my dental problems were caused by my old dentist I have more problems then the average person but I have no idea why I think my dental problems are normal I experienced trauma to my mouth (see below) None of the above
If you experienced trauma, describe the trauma and provide the date:
Has another dentist ever told you why you have more dental problems then the average person? (Optional, share what this dentist said)
I am an environmentally sensitive patient. I prefer to receive holistic dentistry. I am sensitive to: (Check all that apply)

Heavy metal toxicity Allergies to dental materials Have experience a Bad reaction to Dental anesthetic I prefer to be tested for the diagnosis of metal allergy to dental fillings and implants "MELISA Test" I am seeking holistic Dental care None of the above
Please list chemical sensitivities to dental materials:
Intra-oral cameras are used to review oral conditions and provide evidence of dental problems with our patients. Enter your preference:

I like to see visual evidence of dental problems and understand their value during treatment explanations I trust the dentist, but when possible, I like to seeing scientific evidence of dental problems I do not want to see images of any of my oral disease or dental problems None of the above
Risks benefits & treatment alternatives (Check all that apply)

I prefer to review the risks, benefits and treatment alternatives before treatment begins Doctors who share risk of treatment are do it because they don't want to be blamed for their mistakes Reviewing risks of treatments motivates the patient to work with a doctor to decrease the chance of side effects Reviewing risks increases my fears of treatments I will not sign any dental forms, which inform me of the risks of treatment None of the above
Your personal and work schedule (Check all that apply)

I have a very busy schedule at work and home. I worry I might not have enough time for treatment I'm very busy at both work and home. It's hard for me to spend much time at the dental office. Please plan ahead to finish my work efficiently. I would like the doctor to do as much treatment per each visit as is optimally safe My personal and work schedule often changes at the last minute. I'm sorry but I may need to randomly cancel on the same day of my scheduled appointment My work schedule is my top priority. The need to visit the dentist is of secondary importance at this time If my work schedule changes at the last minute, I will need to reschedule my dental appointment. Sorry I don't have a choice I don't have scheduling conflicts. I like to plan ahead and allow block extra time just in case my treatment requires more time If the dentist's schedule is booked up weeks in advance, please call me if someone else cancels, as I may be able to make time and come in for treatment with a last minute notification None of the above
Scheduling vs Dentist running late (Check all that apply)

If the doctor runs late, please call me so I can plan ahead or so that I can consider rescheduling I don't care how long my treatment takes or if the doctor runs a little late. My schedule is flexible I don't want the doctor to feel rushed during my clinical treatments None of the above
Scheduling Vs. Dental emergencies (Check all that apply)

If I have a dental emergency or oral pain, I feel it's only fair that I am seen right away or at least within a few days I don't feel it's appropriate if other patient's last minute emergency treatments are squeezed into the doctor's daily schedule. Particularly if this person's emergency treatments cause the doctor to run late for my scheduled appointment I understand that unanticipated complications may occur during or after dental treatments and that dental emergencies are somewhat normal. I just want to be informed if the doctor runs late None of the above
Dental specialist treatments preference (Choose one)

If there is a dental specialty for a specific dental treatment, I always want to be referred to this specialist for treatments I prefer not to travel to see dental specialists for treatments. I would like to trust Dr Landers to do my specialized dental treatments None of the above
Achieving excellent cosmetic results is profoundly more possible if: (Check all you agree with)

Treatments are not rushed Patients agree to additional visits or an extension of overall treatment time if it's needed A skilled patient who fully understands dentistry in order that they can double-check each step of the doctor's work Doctors who are willing to hard work and have the ability to be adaptive and make adjustments throughout treatment Doctors who are willing to pay attention to the fine details of treatments and results Skilled doctors can achieve excellence with very little effort Doctors with extra training and who have an artistic ability are more likely going to achieve excellent results Dental office that invest in better dental materials & technologies and pays for and uses high quality dental labs Good patient/doctor communication
In general side effects of treatment are the

Dentist's Fault Patient's Fault No One's Fault Can be decreased by a skilled experience dentist, modern treatments, and a healthy patient who follows directions, but there is always a risk for side effects None of the above
Regarding final color match of a crown or veneer: (Check all that apply)

Any dental lab who makes the crown should get it right every time. Patients should not have to make multiple trips to the dental office for color match Poor quality dental labs typically can't get the color correct on the fist time. High quality labs typically get it right every time Patient who are seeking higher quality color match will need to consider the likelihood that multiple extra treatment visits may be required Patients have varying opinions about the color they are seeking. Patients should be allowed to choose a shade before the dental records are sent to the dental lab for fabrication The dentist should be skilled enough to know exactly what each patient wants. The dentist should get it right every time in one visit
Who is responsible for how the chewing surface of a dental crown feels? Share your thoughts:

The lab who makes the crown on an artificial jaw device The dentist who double checks the bite and makes adjustments based on real time patient movements It's subjective; patients should give feed back regarding how their bite feels with the goal to assist the doctor with adjustments All of the above None of the above
Regarding biting adjustments -Share your thoughts: (Check all that apply)

Please get it right the first time. The dentist should not ever have to alter a new dental crown from the dental lab. If he does then the crown is defective. I do not want a crown cemented in my mouth that needs to be adjusted, or reshaped in any way Dental office Bite adjustments are normal, but should only take one visit If the patient is numb they may not be able to bite accurately. As a result, the patient may need to return for additional appointments to balance or adjust the bite forces Bite Adjustments may take several visits over varying amounts of time The number of visits require to balance bite forces is uniquely different for each patient. Each patient's unique ability to coordination tooth to tooth tapping movements and tooth to tooth sliding movements (lateral guidance) will directly affect the ability of the dentist to accurately adjust the bite The patient may not be able to move accurately to the best physical position after just one adjustment. Each time the bite is adjusted the patient will move closer to the ideal physiologic position. Ideally patients should have small bit adjustments and then go home to try it. Then return as needed for bite adjustments until their bite feel really comfortable It's the patient's responsibility to inform the dentist and return in a timely fashion if their bite feels unbalanced or if their new filling or crown is sensitive None of the above

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I prefer treatments which are very predictable even if more tooth structure needs to be removed						I prefer conservative treatments. My priority is to save healthy tooth structure when possible

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At this time cost of treatment will dictate what I choose						Im 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
Im 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 fears

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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

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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

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Please provide Prescription STRENGTH PAIN RELIEVER						I don’t like taking prescription strength pain relievers. Please recommend an over the counter solution

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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

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

	1	2	3	4	5
My work schedule is more 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

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

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I’m a Perfectionist						I like to go with the flow

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Its appropriate to look well groomed, but I think society relies too much on physical appearance						Physical appearance is very important to me

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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

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I want Whiter teeth						I want natural looking teeth to match my existing color

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I want a Hollywood White Smile						I’m seeking to improve my smile. I don’t want to spent time or money with the goal to have a “Hollywood” Smile

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Regarding dental restorations, i.e. Crowns and Veneers, I prefer 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'm 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 it's more expensive, takes longer, and may not last as long

This Section MUST be signed in the office

To the best of my knowledge all of the preceding information is true and accurate.

Patient Signature: _________________________________

Print Name: _______________________________________

Date: ________________
Summary
Type a question

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 Cosmetic Questionnaire E-Form Cyber Consult *Send X-Rays & Images 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. Dental Insurance Information Form (Print, Fill Out & Fax or Email)

3. Medical Health History E-Form

4. 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 Cosmetic treatment, its “Very important” that you fill out:

Cosmetic Questionnaire

.

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

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Personal Preferences Patient Communication E-Form

Summary