Your needs
Enhancing the profile of the nose
Enhancing your smile
Sleep apnea
Oral surgery under hypnosis
Reducing jaw tensions (grinding/TMJ)
Removing wisdom teeth
Smoothing wrinkles
3D Radiology
Revive the radiance of your complexion
Replacing teeth (implants)
Repositioning my jaws (facial harmony)
Sinusitis
Our treatments
Dental Implants
Bone Graft
Wisdom teeth
Orthognathic Surgery (Jaw Repositioning)
Trauma / Fractures of the Face
Tempromandibular Joint Pain (TMJ)
Oral Pathology
Obstructive Sleep Apnea Syndrome (OSAS)
3D Radiology (Cone-Beam CT Scan)
AESTHETIC MEDICINE / BOTOX / FILLERS
Hypnosis
Patient information
Referring Physicians
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Referring Physicians
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Date
Patient data
Name
*
First name
*
Date of birth
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Parent/legal representative
E-mail address
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Telephone number
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Should the patient take antibiotic treatment before surgery?
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Yes
No
Should the patient be called back or will the patient call back?
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The patient will call to make an appointment
Please call the patient
Information regarding the referring doctor
Referred by
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E-mail address
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Telephone number
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Consultation
Consultation
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ATM
Cleft lip
Bone graft
Implants
Cosmetic
3D Radiology (CBCT)
Orthognathic Evaluation
Increased bone volume
Wisdom teeth
Pre-Prosthetic
Oral/Facial Injury
Other
X-rays / Clinical Photos
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Given to patient
Please complete the Rx/photo assessment
No x-rays
Implants and surgical guide (optional)
Implants
Surgical guide
Radiographies / Photos Cliniques
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Other interventions
Other interventions (optional)
Extraction (see graph)
Evaluation of a lesion
Alveolar plasty
Discovery of an implant
Biopsy
Infection
Incision and Drainage of an abscess
Frenectomy
Other
Extractions (optional)
Extractions (optional)
Teeth to be extracted
Remarks
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