Sarasota Cosmetic Dentist Dr. | Charles E. Crane, D.D.S.

dr. charles crane dds, cosmetic and reconstructive surgery

Please fill out the form below to have a member of our staff contact you to schedule your consultation. You may also contact us directly by calling 941-923-3802

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Mr.

Dr.

Ms.

Mrs.

First Name

Last Name

Telephone

Address

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What are your Health and Cosmetic expectations?

Is there a concern that needs urgent attention?
	Yes	No

If Yes, please describe.

When was your last dental hygiene?		What comfort and sedation options have you experienced that worked for you in the past?
	Within the last year
	2 years ago		I.V. Sedation
	3 years ago		Oral Sedation
	4 years ago		Nitrous Oxide
	5 years ago		Music
	More than 5 years ago		Eye Pillows
			Not sure / None

Do you have a current x-rays and type?		If yes, what type(s)?
	Yes		Bitewings/Cavity detecting x-rays
	No		Full mouth series
			Pano
			Digital
			Film
			Not sure

Is there a special event you would like to have your transformation completed for?
	Vacation	Reunion
	Wedding	Anniversary
	Promotion	Other
	Birthday	No special event

How soon would you like your transformation to be completed?

May we assist with travel, accommodation and concierge services?
	Yes	No

If Yes, please describe your needs

How do you prefer to be contacted?
email
telephone
mail

Our patients' restored smiles have been the greatest testimony of what we offer. Whom did you have the opportunity to meet, or how did you hear about us?

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You will immediately receive an email confirming receipt of this form, and will be contacted in 24 hours to schedule your consultation

Thank you!

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