Your Preferences Your name* Prefix First Last Suffix Your practice Name*Email address* Enter Email Confirm Email Business phone number?*Reporting PreferencesWhich of the following reports should we send to you?*(Choose all that apply) Initial visit report; this will be sent immediately after our first visit with your patient. It will indicate the need for treatment, where we are in treatment and when the case is expected to be finished. Progress report; sent to report progress in complicated cases that will take multiple appointments to finish. Final report; this report will be sent immediately after treatment is completed and will indicate that treatment is finished, what type of restoration has been placed and what further restorative needs there are. Failed appointment report; this report is sent when the patient fails an appointment. Termination report; this report is sent when a patient is dismissed from the practice. Usually the result of multiple missed appointments. Other Considerations Please explain any other reporting considerations you want us to address. Restorative PreferencesPerform restoration in crowned teeth?*AlwaysCall MeNeverPreferred material*AmalgamBonded compositeUse our discretionPerform core build ups?*AlwaysCall meNeverPreferred material*AmalgamBonded compositeUse our discretionWe would normally place an immediate bonded composite core in teeth with fractures, is that OK with you?*YesCall meNeverPosts?*AlwaysCall meNeverIf we do not do the post would you like a post space placed?*YesNoPreferred post material?*Choose oneSteelCarbon fiberCall meDo you have a preferred brand or brand(s)?*YesNoPlease list your preferred brand or brand(s)*Please detail any additional information we should know about your restorative preferences?If applicable. Extraction PreferencesWhich of the following extractions should be referred back to you?*Anterior and bicuspidsmolarsallnoneShould we make the referral for you?*YesNoFirst choice of oral surgeon?*Doctor's nameSecond choice of oral surgeon?*If none, please indicate such.If we feel that treatment or consultation to a periodontist is indicated should we:*make a referral for you at our discretion?make a referral for you after consultation with you?refer patient back to you for treatment or referral?First choice of periodontist?*Doctor's nameSecond choice of periodontist?*If none, please indicate such.Your staffPlease introduce your staff to us;Receptionist(s)Click the plus sign to add additional names Office managerAssistant(s)Click the plus sign to add additional names This iframe contains the logic required to handle Ajax powered Gravity Forms.
