Registration Form

We would like to get to know you better.

Personal Information

Address

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?*

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