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Online Treatment with Cosmetic Dentist Request

This online consultation form is available for patients who are unable to visit our Blackburn office and is currently reside outside of Melbourne, VIC. All submissions are completely confidential and used for the purpose of treatment planning and office use only. The online consultation form is designed to establish the most appropriate treatment outline for the individual needs of all our patients. We will also require a submission of appropriate images. Vogue Dental Studios ensures that all our patients will be treatment with the ultimate level of attention and care.

After the form is completed, we will determine your candidacy for the treatment in which you request. Our office will be able to assist you in scheduling all your appointments and itinerary after your phone consultation appointment. If you have any questions or issues in regards to the form, please call us on 1300 764 536.

Please note that all questions must be filled in before the form can be submitted.

ONLINE CONSULTATION FORM

Online Cosmetic Dentistry & Smile Makeover Consultation Request

Personal information

ADDRESS

CONTACT INFO

WORK RELATED INFO

EMERGENCY

Consultation Information


Medical History

Do you have or have you ever had any of the following?

High Blood Pressure
Heart Trouble/Attacks
Difficulty walking 2 blocks
Heart Murmurs
Eye Diseases*
Dry Eyes*
Thyroid Problem*
Asthma
Anemia*
Blood Disorders*
Skin Disorders*
Immunity problems*
Prolonged bleeding with dental work or cuts*
Problems with scars/keloids*
Any other serious illnesses?*
Gum Disease*
Dermal Fillers*

Cancer
Kidney Problems
Ulcer/Heartburn
Stomach/bowel problems*
Heart Palpitations*
Irregular Heart Beat*
Chest Pains*
Shortness of Breath*
Swelling of Ankles*
Rheumatic Fever*
Herpes “Fever Blisters”*
Sleep apnea*
Chronic Lung Problems*
Diabetes*
Easy bruising*
Botox/Dysport/Muscle Relaxants*

Women only

Are you pregnant?

Anesthesia

Have you or any family members had a problem with general anesthesia?

Have you had any allergic reactions to lidocaine, epinephrine or local anesthesia or problems with numbing agents during dental work?

Medications


Allergies to medication


Do you smoke?

Do you drink?

Previous drug use?

Are you under the care of psychiatrist, now or ever?

By typing in your name below, you are agreeing that all of the above information is completely accurate and true. You understand that false disclosure of medical information may be harmful and compromise your entire treatment, care and may cause severe complications. You also understand that failure to provide precise information may cause your treatment to be terminated.

Your Name:

Date:

In order to treatment plan you, you must send us clear images of your front and side views (see template attached). Photos should be taken in good lighting and clearly show your areas of concern. Multiple photos can be uploaded via a ZIP folder or alternatively you may email the images to info@vogudentalstudios.com.au with your name as the subject.

Max file size 4mb. Accepts gif, png, jpg, jpeg, zip.


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Request a call back
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I’m Intan from Vogue Dental Studios! Let me assist you with a confidential call back at a time that suits your schedule. Simply fill out the form with your details below.

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Online Consultation Form
Author
I’m Intan from Vogue Dental Studios! Let me assist you with a confidential call back at a time that suits your schedule. Simply fill out the form with your details below.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Thank you for submitting an online consultation form

A Vogue team member will be in touch with you as soon as possible.