Patient’s Information

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Patient's information

Name:
Date of birth:*
/
/
Address:
E-mail:

Telephone consultation

Telephone:
-
Time of phone consultation:
 : 
 : 
Available Days:
What information would you like to receive during your phone consultation?

Teeth to be replaced (in your opinion):

Maxilla
jaw teeth position number of adults
Mandible

Your last dental consultation

Have you already been consulted for this intervention?
If yes, what were the conclusions:
Do you have a panoramic x-ray going back to less than 3 months?
If YES, attach your x-ray:

If you can’t send us your panoramic X-ray through this page, or if the file is too large, you can send it by mail to info@anveli.info . Panormaic X-ray is essential for making your quote.
Also, you can contact our English speaking service on 00359 884 169 710

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