Please fill out our inquiry form by providing the information requested. NOTE: An Asterisk (*) Indicates REQUIRED Information. We look forward to answering any questions or concerns you have. All messages and personal information will be kept strictly confidential. Someone from our office will follow up with you shortly!

*Complete Name:
Address:
City:
State:
Zip:
*Email:
*Confirm Email:
Date of Birth:
Home Phone:
Best time to contact you?
May we contact you at work? Yes
No
Work Phone:
Cell Phone:
1.) Which bisphosphonates have you used or being treated with:
Alendronate (Fosamax)
Risedornate (Actonel)
Etidronate (Didronel)
Tiludronate (Skelid)
Ibandronate (Boniva)
Zoledronate (Zometa)
Pamidronate (Aredia)
2.) Check all of the following symptoms you experienced while being treated with bisphosphonate:
gum pain
gum swelling
gum infection
loosening of teeth
numbness in jaw
feeling of heaviness in the jaw
poor healing of gums
jaw pain
lesions in gum
jaw swelling
exposed bone in jaw area
lesions in mouth
jaw numbness
pain in or around the eye
pain in cheek bone
stomach ulcer
other
Have you reported these symptoms to your doctor/dentist/periodontist/oral surgeon? Yes
No
if "yes", what did you tell your doctor?
Approximate date of conversation?
What did your doctor tell you or what treatment were you prescribed?
Doctor's Name:
Address/Phone:
3.) Have you been diagnosed with Osteonecrosis? Yes
No
If "yes", date of diagnosis:
Doctor's Name:
Address/Phone
Treatment:
Status of Treatment:
4.) Have you been diagnosed with any of the following?
Alveolar Osteitis (dry socket)
Sinusitis (sinus infection)
Gingivitis (gum disease)
Periodontitis (advanced gum disease) Caries (cavities or decay) Periapical Pathology
Temporomandibular Joint Disorders (TMJ)
If any of the above are checked, date you were diagnosed?
 
 
© 2008 Zimmerman Reed.
Legal Notice | Site Map | Inquiry Form | Back to Top