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Beverly hills

New patient info

Patient Name:    
       
Email:    
       
Day Time Phone:    
       
Evening Phone:    
       
Are you happy with the way your smile looks?
Yes No
 
     
Are you embarrassed about smiling in front of people?
Yes No
 
     
Do you ever put your hand up to cover your smile?
Yes No
 
     
Do you dislike your smile in photographs?
Yes No
 
     
Do you have crooked, misaligned, or off-centered teeth?
Yes No
 
     
Do you wish your teeth were white?
Yes No
 
     
Do you have gaps or spaces between your teeth?
Yes No
 
     
Are you considering braces for that perfect smile?
Yes No
 
     
Do you show your gums when you smile?
Yes No
 
     
Do you have missing teeth?
Yes No
 
     
Would you like to change the way your teeth or gums are shaped?
Yes No
 
     
Anything about your teeth or smile would you like to change?
Yes No
 
     
What will happen on your first visit:  
 

This is the most important appointment that a patient will have at Dr. Soleimani-Farnad's office. A detailed history will be carried out which includes:

1) An extra -oral examination of all hard and soft tissues, facial symmetry, smile line and the skeletal relationships.
2)An intra-oral examination which includes using of intra oral cameras and microscopic examination of all soft and hard tissues, periodontal examination, full mouth scan and study models can be provided if required. All of these informations allow us to develop a detailed customized treatment plan. Then a comprehensive treatment plan including all costs as well as coordination of insurance benefits will be discussed.


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