POST-TREATMENT EVALUATION FORM

Date

Name - Surname

Phone

E-mail

Original Treatment Date

Please answer the following questions carefully.

1- What is your main complaint? (Pain, loosening, fracture, food impaction, aesthetic appearance, etc.)

2- Have you experienced any trauma related to your teeth? (e.g., falling, impact, biting hard objects)

No

Yes (Please explain)

If you answered “yes” to the question above, please explain.

3- In your personal opinion, what do you think is the cause of the problem?

Please take your photographs as shown in the diagram below and upload them together with your X-ray. You will be notified within 5 working days of submitting the form.

+49 178 436 32 81

+44 730 724 44 01