Registration Form

We would like to get to know you better.

Personal Information


Contact Information

Do you have any conditions or allergies that you would like to inform us about?*

Are you a smoker?*

Have you ever had Hepatitis A, B, C?*

Are you HIV positive? (AIDS positive)*

Do you take any medications at this moment?*

Do we have your consent to take x-rays, should it be needed during the treatment?*

Have you been infected with COVID-19?

Do you agree to have photographic images of your face and teeth which are required to plan and document your treatment?*

How did you hear/find about our dental clinic?*

How can we help you? Please, describe with few words, what is the reason that you seek our dental services?*

Do you have any relatives or close friends who have visited or are treated by us?*

Този уеб сайт използва бисквитки. Ако сте съгласни с това, моля продължете разглеждането.

Прочети повече