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Leodent Dental Clinic

{ Leodent Dental Clinic }

Online Consultation & Comprehensive Patient Assessment

Please complete this form as accurately as possible. It helps our dental team understand your needs, medical background and expectations, so we can prepare a personalised assessment before your visit. All information is kept strictly confidential.

Fields marked * are required. This online consultation is an initial assessment only — a final diagnosis and treatment plan are confirmed after a clinical examination.

Leodent Dental Clinic — reception

Leodent Dental Clinic

Caddebostan, Kadıköy · Istanbul

01

Personal Information

02

Chief Complaint

What is the main reason you are seeking dental treatment?

Main reason
03

Main Goals & Expectations

What would you like to achieve with your treatment?

Goals
04

Current Dental Symptoms

Are you currently experiencing:

Symptoms
05

Dental History

Have you previously had:

Previous treatments
06

Previous Implant History

Have you ever had dental implants?

Had dental implants
07

Oral Hygiene Habits

How often do you brush?
Do you floss?
Do you use mouthwash?
Professional cleaning
08

Medical History

Do you have any of the following?

Conditions
09

Medications

Please list all medications you currently take.

10

Allergies

Do you have allergies?

Allergies
11

Smoking & Alcohol

Do you smoke?
Do you vape?
Alcohol
12

Bruxism (Teeth Grinding)

Have you ever been told you grind or clench your teeth?

Grinding / clenching
13

Sleep

Diagnosed with sleep apnea?
Do you snore?
14

Dental Anxiety

How anxious are you about dental treatment?
Would you prefer sedation?
15

Smile Evaluation

Which of the following bother you most?

Concerns
16

Functional Problems

Functional problems
17

Desired Treatment

Which treatments are you interested in?

Treatments of interest
18

Timeline

When would you like to start treatment?

Start timeline
19

Budget

What budget have you allocated for your treatment?

Budget
20

Travel Planning

Have you visited Türkiye before?
Will you travel alone?
21

Accommodation

Would you like assistance with:

Assistance
22

Communication Preference

Preferred communication
23

Documents Available

Can you provide?

Documents
24

Additional Information

Please tell us anything else that may help us plan your treatment.

25

Patient Declaration

I confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that this online consultation is an initial assessment only. A definitive diagnosis and final treatment plan will be confirmed after a comprehensive clinical examination and appropriate radiographic evaluation.