Gabinet Stomatologiczny, Gdynia - Lekarz stomatolog Jacek Wyszkowski en
Consultation

This consultation presented hereby has got an approximate meaning only and cannot substitute a final treatment plan which can be solely established after a surgery session. Please fill in a form given below and enclose a panoramic X-ray picture scan or (in case of minor lacks) a single, small picture. You can attach 3 pictures maximum. Personal details gathered in this questionnaire are anonymous and will be used exclusively for surgery’s needs. You will receive a response within a week to the address given by you in your questionnaire.

Please, enclose a panoramic X-ray picture scan or (in case of minor lacks) a single, small picture. You can attach  picture in JPG or GIF format.

Initials:
  *
e-mail address:
  *
Age:
  *
Sex:
Have you already got any dental implants?:
Yes
The last implanting procedure was carried out in...:
How do you estimate the implanting procedure’s effect? (1 fatal - 10 perfect):
Have you got a tendency for tartar accumulation?:
Yes
Do you smoke?:
Yes
Do you grind your teeth?:
Yes
Have you got bleeding gums?:
Yes
Do you suffer from high blood pressure?:
Yes
Of what estimated values?:
Do you suffer from diabetes?:
Yes
Why do you decide to undergo implanting procedure treatment?:
Attach File:
Send me a copy
* Required field