Clinical Consultation

Step 1 - Clinic Background

Questions and answers feature for members/one-time users, with check box entry via username and password

We hope to be able to address your expectations, so please tell us what
is your reason for contacting us? What answers are you hoping to receive from us? If you are the patient or a parent:
Have you been referred by a dentist or orthodontist?    Yes No
Have you consulted an orthodontist or received advice?    Yes No
Please give name and e-mail address of orthodontist if any:
Name        E-mail address

Questions for all applicants:
Please give patient's age and sex male female
Please give background of patient's general health
Medical history - give details:
Present medical condition - give details:
Has the patient been advised that he/she needs antibiotic cover for
dental treatment? Yes No
Please note all medicines taken on a regular basis
Does the patient take bisphosphonate drugs (for osteoporosis etc) on a regular basis? Yes No
Does the patient have any allergies?

Please assess the level of oral hygiene maintenance

Please give an assessment of the general health of the teeth and gums


Please list teeth with large restorations, root canal treatments and teeth with poor prognosis.
Please send any radiographs as attachments to the following e-mail: info@dr-adrianbecker.com
Do not arbitrarily perform further radiographs before being advised to do so.
Please also send intra-oral photographs of the teeth in occlusion, occlusal and full face views as attachments.


Do you have any specific question that this questionnaire has not
addressed?

If you have a problem with this questionnaire
please email to info@dr-adrianbecker.com




Step 2 - Payment

The charge for the initial consultation and e-mailed reply with a general assessment on the basis of the material presented, will be US$150 (VAT will only be applied where legally required). A definitive plan for recommended treatment may require additional records (radiographs, CBCT etc), in which case these will be listed. Completion of the consultation with a diagnosis and suggested treatment plan, following submission of these additional records may incur a further fee, in which case this will be stated in the initial e-mailed reply.

* I wish to pay for initial advice for this case only - cost US$150 (VAT will only be applied where legally required)

First name     Family name
Email *
Address
City      Postal code
State      Country

Disclaimer: The advice and recommendations given here must be viewed with caution as they are based only on the information provided without the possibility of a thorough clinical examination by Dr. Becker and in the absence of any other possibly relevant information. They are intended only as an aid in diagnosis and treatment planning and are for the practitioner to take into consideration before deciding upon a definitive treatment plan, for the outcome of which he/she alone will be fully responsible.
* I have read the disclaimer