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Whatsapp or call: 072 580 6122
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Please complete the form as accurately as possible. This will
improve
your experience during the booking process.
Step 3.
1. Medical History
Please indicate whether you have any of the following conditions
None of these
Rheumatic Fever
Porpheria
Arthritis
Diabetes
Heart Conditions
Lung Conditions
Cortisone therapy
Asthma
Blood Clotting Problems
Are you pregnant?
High Blood Pressure
Epilepsy
Allergies
Radio Therapy
Any other medical conditions, medication, operations, or prosthesis?
2. Dental History
Please select your main complaint. You may select mutiple complaints.
-Dental pain
-Gum pain
-Swelling
-Bleeding
-Broken or cracked tooth
-Bad taste in your mouth
-Signs of infection (may include visible abcess and/or discharge)
-Other
If you are experiencing pain, which of the following would best describe the pain. You may select more than one option.
Dull/throbbing pain
Sharp/shooting pain
Sensitive/pain to Hot
Sensitive/pain to Cold
When did you first experience any symptoms?
Please provide additional information regarding your main complaints
Have you previously seen a dentist for this specific complaint and if *Yes, how did the dentist treat it?
All of the obove informatin is correct and complete. I agree to the terms & conditions
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