Dr. Mesut Hepgüler Clinic
HepDentist – Happy Smiles
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🦷 Free Dental Evaluation Form
Our dentists will review your information and contact you soon.
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Treatment Type
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Implant Treatment
Teeth Whitening
Orthodontics (Braces / Clear Aligners)
Root Canal Treatment
Tooth Extraction / Oral Surgery
Gum / Periodontal Treatment
Restorative (Filling / Crown)
Prosthetics (Bridge / Denture)
Esthetic (Laminate / Veneer)
General Check-up / Cleaning
Other
Patient Information
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Other
Additional Notes (optional)
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🩺 These sections are optional — the more details you provide, the better we can evaluate your case.
General Health
Dental Health
Diabetes
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Heart Disease / Pacemaker
Bleeding Disorder
Cancer / Chemotherapy
Organ Disease
Autoimmune Disease
Pregnant / Breastfeeding
Allergy
Tobacco Use
Alcohol Use
Surgical History
Tooth Pain
Sensitivity
Gum Bleeding
Loose Teeth
Cavities / Fillings
Missing Teeth
Bruxism
Jaw Problems
Dry Mouth
Aesthetic Concerns
Last Dental Visit
Treatment Done at Last Visit
Agreements
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