The dental clinic specialises in aesthetic dentistry, dental reconstruction, implantology and teeth whitening techniques

Contact to consider a treatment

How to contact us :

1.Inscription formulated on Internet with review, medical questionnaire and essential characteristics of request.

2.Exchanges of elements by Internet: numerized photographs and panoramic radio.

3.Direct Appointment by webcam with the practitioner; timetable predefined by mail.

4.In return, second direct date by webcam with the practitioner who will itemize elements addressed the same day by mail with the plan of treatment and a consisting of approximated quote :

- The entirety of medical interventions.
- Reservation of the plane.
- Reservation of the hotel .
- Dislocate transportation and any displacements during stay in car.

5.After agreement and transfer of a down payment they fix the first Date in Paris.

6.Care blocked : interventions programmed over one week.

You will need to obtain a digital panoramic x-ray, copied to a CD-Rom or USB key, from an x-ray clinic, which must be sent to us by e-mail (or ask the x-ray clinic to send it directly to us at immediatsmile@yahoo.fr ). A series of digital photos of your smile (the mouth only) is also required, both close-up and overall view.

In order to treat you in conditions of maximum safety and guarantee you the very best dental care, we need information about your state of health and any medical treatment you may be currently undergoing. 

This is why we ask you to kindly reply to the following questions.  Each of the answers you provide may be directly or indirectly connected with your dental treatment. 

The most recent studies have shown that the teeth can be involved in pathologies developing throughout the body. 

Your answers to this medical questionnaire will allow us to know you better and therefore give you better treatment.

Formulaire
Contact details
Last Name * :
 
    Enter your last name.
First Name * :
 
    Enter your first name.
Full adress * :
 
    Enter your full postal address.
E. mail * :
 
    Enter your Email address.
Fixed telephone :
 
    Please enter your fixed telephone number (with the country code if necessary) if you have one.
Mobile phone :
 
    Enter your mobile phone number if you have one.
Birth date * :
 
    Enter your birth date.
Occupation * :
 
    Tell us more about your job.
     
Morphology
Height * :
 
    Enter your height with units.
Weight * :
 
    Enter your weight with units.
     
Life style
Diet * :
 
   
    In the event of dietary restrictions, please provide details.
Sleep * :
 
   
    If you use medication to help you sleep, please provide details.
Sport * :
 
   
    Which sport do you practise ?
Tobacco :
 
    If you smoke, please indicate the average number of cigarettes per day.
Alcohol :
 
    If you are alcohol-dependant, please give details.
Drugs :
 
    If you are drug-dependant, please give details.
     
Illness / disability
Cardiovascular Disease :
 
    Please state which if appropriate.
Lung Disease :
 
    Please state which if appropriate.
Kidney Disease :
 
    Please state which if appropriate.
Digestive Diseases :
 
    Please state which if appropriate.
Neurological disorders :
 
    Please state which as appropriate (headaches, faintness, dizziness, etc).
Hormonal disorders :
 
    Please state any hormonal disorders.
Date of last blood test * :
 
Presence of Viruses :
 
    If yes, please give details.
Coagulation problems :
 
    Coagulation time.
E.N.T * :
 
   
    Please give more details if necessary.
Allergies :
 
    Please give more details if necessary (pollen, medication, etc).
Surgical operations since birth :
 
Surgical operations planned for the months to come :
 
Recent hospital treatment (within one year) :
 
Pregnancy :
 
    Expected date of confinement.
     
Dental questionnaire
Are you satisfied by the appearance of your teeth ? * :
 
Do you like the shape of your teeth ? * :
 
If not, what is it that you do not like ? * :
 
Do you have any metallic or other fillings ? * :
 
Do your gums bleed readily when you eat or brush them ? * :
 
Are your gums painful ? * :
 
Are you concerned about the freshness of your breath ? * :
 
What are the aims of the treatment you may request ? * :
 
Please give details of the results you are looking for :
 
What do you require in terms of comfort during the treatment ? * :
 
At what times GMT can you make contact with the Dentist for a prior webcam meeting ? * :
 
Merci de remplir tous les champs (*)
Documents
Before any connection with the Dentist you must send him a digital panoramic x-ray and digital photos of your natural and open smile with your lips apart. If you wish you may also send these documents by e-mail (immediatsmile@yahoo.fr) instead of via this form.
 
Links
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Docteur Jean-Pierre TOUBOL - 242, rue de Rivoli - 75001 Paris
Tel : + 33 1 40 15 63 44 - Fax : + 33 1 40 15 63 84 - Mail : immediatsmile@yahoo.fr
 
© 2009 Atoutmédia