Dr. Robert M. Dery, DDS, Cosmetic Dentistry, Bingham Farms, MI

Robert M. Dery, D.D.S.
24255 W. 13 Mile Rd. #170
Bingham Farms, MI 48025
_________________________

P. 248-646-4068
F. 248-646-4839

	Our Office

This form allows Dr. Dery to do a preliminary review of your case online. Please fill out the form to initiate this process. We will review your case and contact you as soon as possible to go over your dental options. Thank you for contacting our practice.

	Please answer all questions
	Patient Name:

	Email Address:

	Phone Number:

	1. List in priority the things you would most like to improve about your smile.

	2. Have you had any previous aesthetic dentistry? (If no, go to question #4.)

	a. What was the reason for your previous work?

	b. When was your last dental visit?

	c. Who was your dentist? (name of doctor)

	3. Do you have any interest in teeth whitening?

	4. If you have not had other dental aesthetics, what are your realistic desires? (i.e. What will/would it take for you to be satisfied with the outcome?) Think about this and be honest.