Patients Form

Patient registration form. Please complete the boxes with an (*). This is mandatory.
The information will be confidential and for the exclusive use of the clinic. In case the patient is a minor, he must be accompanied by his parents.



Day Month Year

Dental Hygiene*:


Do you smoke?*
NoA littleA lot

Do you drink?*
NoA littleA lot

Are you preagnant?
YesNoDoes not apply

If you answered yes, please indicate the following:

Number of weeks:

Due date:

Physician name: :

Physician name: ´s phone:

Do you take medication (List) *

Any Allergist (to medicines, Antibiotics, local anesthesia, latex, AINES or others)*

NoneFaintingChemotherapyAbnormal bleedingAnemiaHemophiliaKidney DiseaseGlaucomaCancer or TumorRespiratory ProblemsPaceMakerHeart SurgeryHeart conditionArthritisRheumatic FeverOrgan TransplantChest PainTuberculosisHigh blood pressureConvulsionsOsteoporosisJoin ReplacementDiabetisHepatitisGastritisUlcersColitisEpilepsyHIV-SIDAArterioesclorosisHeart Murmor*

*Some heart Murmur require pre-medication for Dental care. Please check with your Physician.

Any other Medical Condition not mentioned above:

Referral - Whom may we thank for referring you?

× How can we help you?

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