If you have gum disease or have receding gums during your first visit, Dr. Caudill will examine your gums, check to see if there is any gum line recession, assess how your teeth fit together when you bite and check your teeth to see if any are loose.  The doctor also will take a small measuring instrument and place it between your teeth and gums to determine the depth of those spaces known as periodontal pockets.  This helps Dr. Caudill assess the health of your gums.  If your first visit is for implant consultation, x-rays will be needed. Please bring copies of any relevant x-rays from your referring dentist. Your mouth will be examined to see if there is enough bone quantity and quality for dental implant placement. Additional diagnostic procedures may be required. 

   Name*
 Address
 City
 State
 Zip
 Home Phone*
 Work Phone
 Email*

When are you interested in coming to our office?
 Mon  Tue  Wed

 Time   AM      PM

Who may we thank for referring you?
 

Purpose of Appointment:
 Perio Exam  Implant Consultation  Other

Do you pre-medicate for dental visits? Yes  No

Do you take blood thinners (including aspirin): Yes  No

Is there anything else in your medical history that we need to be aware of?

X-Rays: Bringing IN   Dr. Sending   No X-Ray*

Notes:

If you are missing teeth and need dental implants for fixed tooth replacements. Dr. Caudill will examine your mouth and take X-rays of the area (bring current ones if you have them). Then advise you as to the feasibility of having dental implants. He will answer andy questions you might have and explain implant therapy fully.


*Full payment is expected at time of service. Our office can file insurance claims for your reimbursement. Please remember that if you have an HMO plan, you may not be eligible for reimbursement since your plan requires you to visit a pre-selected doctor.

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