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Discover European Dental Care - Dental Practice Dr. Georg Onodi - Munich, Germany

High German Quality
At Practice Dr. Onodi

Call Us Today at
UK: +44(0)20 8144-1840
US: +1(877)700-3260
for your FREE quote!

Dental Travel Quote Request Form

Please use this form to submit your information to us.

Our servers use SSL encryption to ensure safe transmittal of your data. If you prefer, you can alternativly fax a printable version of this quote request form to: +1(954)575-1151. Please fill out this form with your information. This will help us prepare a personal non-binding treatment plan for you. Please also use this form to upload your x-rays, if available. We will get back to you shortly, and show you all the options we can offer you.

Registration/ Dental Travel Inquiry Form

Step 1/3 - Personal Information
Title: This field is required.
First Name:* This field is required. Last Name:* This field is required.

Email:* This field is required.

Home Phone:* This field is required. Cell Phone:* This field is required.

Mailing Address:* This field is required.

City:* This field is required. State (US): This field is required. Postal Code/ Zip Code:* This field is required.

Country:*
This field is required. Date of birth: This field is required.

Click on the teeth below to tell us about your dental condition,
or click here to enter the details maunally

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Top Right

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Bottom Left

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Bottom Right

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Step 2/3 - Dental History
Date of Last Dental Visit: This field is required.
Date of Last Cleaning: This field is required.
Date of Last full-mouth X-rays: This field is required.
Dental problems - Please be as specific as possible: This field is required.

Are any of your teeth sensitive to:

Hot or Cold?
Sweets?
Biting or chewing?
Have You noticed any mouth odors or bad tastes?
Do You frequently get cold sores, blisters or other oral lesions?

Do You:

Bite your lips or cheeks regularly?
Clench or grind your teeth while awake or asleep?
Smoke/chew tobacco?

Your Gums:

Have you noticed loose teeth or a change in your bite?
Do your gums bleed or hurt?

Have You Ever Experienced:

Headaches, neckaches or shoulderaches?
Difficulty in chewing on either side of the mouth?
Difficulty in opening or closing the mouth?
Pain? (joint, ear, side of face)
Clicking or popping of the jaw?
Sore muscles (neck, shoulders)?

Have You Ever Had:

A bite plate or mouth guard?
Periodental Treatment?
Oral Surgery?
Orthodontic Surgery?
A serious injury to head or mouth?

Do You feel anxious about dental treatment? If yes, please tell us your conern(s):

Have you ever had a upsetting dental treatment?

Is there anything else about dental treatment you would like us to know?

Step 3/3 - Medical Information
Physicians Name: Physicians Phone Number:

Please list medications you are taking: Please list any allergies you have:

If you've been to the hospital in the past 5 years, please explain:

Please explain if you've been under the care of a medical doctor:

Please indicate which of the following you had or have at present:

Please list any other conditions not listed above:

Women only - are you

Taking birth control?
Nursing?
Pregnant?

X-Ray Upload: Please upload your x-rays here:

Attach another File
Maximum file size is 400kb,
allowed file types: "jpg", "jpeg", "gif", "bmp", "pdf"

We respect your privacy, and will only use your information to generate a personalized free estimate for you, and will not pass on your data to any third parties. Please read our privacy policy for more information.

High German Quality At Practice Dr. Onodi

Dental Travel Quote Request Form

Please use this form to submit your information to us.

Registration/ Dental Travel Inquiry Form

High German Quality
At Practice Dr. Onodi