"First class and cheap dental implants with experienced and reliable dentists in the safe heart of Europe."

Treatment Confirmation Form

If you decided to have your dental treatment with Dental Implants Abroad; please fill out this form. All information provided is protected by medical confidentiality. If you have any questions, please do not hesitate to contact your Dental Personal Assistant.

We value your email privacy and will never share your details. Privacy policy

First Name(s) (required)
Last Name (required)
Date of birth (required)
Your Email (required)
Phone - The country code can be changed by simply deleting the given one.
Your town/city of residence

Pre-Operative Questionnaire

Do you have / did you have any of the medical conditions / diseases listed below? If yes and if necessary please write additional information.

1. Allergy (to what?)
2. Epilepsy
3. Respiratory diseases (which?)
4. Bleeding disorder
5. Diabetes (which type?)
6. Glaucoma (higher pressure int he eyes)
7. Hematologic diseases (diseases of blood producing organs)
8. Cardiovascular disease
8.1 Heart failure
8.2 Coronary heart disease / Angina pectoris
8.3Heart attack
8.4 Heart rhythm disturbances
8.5 Pacemaker
8.6 Valvular heart disease / - compensation
8.7 Hypertension (high blood pressure)
8.8 Hypertension (low blood pressure)
8.9 Hypo perfusion of the CNS/Apoplexy
9. Infections
9.1 Hepatitis
9.2 AIDS
10. Liver diseases
11. Gastro-intestinal diseases
12. Kidney disease
12.1 Chronic renal failure
12.2 Dialysis
13. Osteoporosis
14. Rheumatoid arthritis
15. Thyroid diseases
16. Tumor diseases
17. Previous operations (which?)
18. Are you afraid of the treatment?
20. Are you pregnant?
21. Do you take any medication? (all regularly taken ones, even Aspirin) (required)
22. Do you smoke? (if yes, how much/day) (required)

YES! I want to book this treatment to the date mentioned above.

ATTENTION: Your request is important to us so if you, after you have submitted your request, were not redirected to another page within few seconds and have not received a confirmation e-mail (please also check your spam folder); please reload the page, fill out the form and press the 'SUBMIT' button again.
If the retry has failed, please contact us on , e-mail address or call us on +44 20 3769 3987.

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