CONSULTATION FORM FOR EDENTULOUS PATIENTS

CIS	PROSTHETIC DESIGN	COMMENTS	FEE
1	SIMPLE OVERDENTURE	_	_
2	HYBRID PROSTHESIS	_	_
3	COMPLEX OVERDENTURE	_	_
5	CROWN AND BRIDGE (CERAMO-METAL)	_	_
	IMPLANT LOCATION
1	ANTERIOR MANDIBLE	_	_
2	ANTERIOR MAXILLA	_	_
3	ANTERIOR/POSTERIOR MANDIBLE	_	_
4	ANTERIOR/POSTERIOR MAXILLA	_	_
	SURGICAL TYPE (0-4) *
_	AVAILABLE BONE VOLUME	_	_
_	BONE DENSITY	_	_
_	ANATOMICAL LANDMARKS	_	_
_	GENERAL MEDICAL CONDITION	_	_
_	IMMEDIATE IMPLANTS	_	_
	PHYSIOLOGICAL TYPE	_	_
1	AGE	_	_
1	OCCLUSAL FACTORS	_	_
1	ORAL HYGIENE	_	_
1	PSYCHOLOGICAL TYPE	_	_

* A 0 grade indicates no impact on surgical success of implant placement. A 4 grade indicates no chance of successful implant placement.

COMPLEXITY INDEX: _______