Registration formBleaching formMedical history form Please answer the following questions: First name(required) Surname(required) Marital Status(required) Cellphone number(required) Email address(required) Date of Birth(required) I.D. Number(required) Occupation(required) Home Language(required) Person Responsible for Account Title Mr Mrs Miss Ms Full Name Email address Home Address Work Address Postal Address Cellphone number Medical Aid Name Number Main member's name I.D. Number Dependents A Dependents B Dependents C Nearest Family Name and surname Relationship Address Cellphone number Referred By Name and surname Address Cellphone number Family Details A. Names Date of Birth Allergies B. Names Date of Birth Allergies C. Names Date of Birth Allergies Type the characters(required) This field should be left blank Send Please wait... Please answer the following questions: Name and surname(required) Cell number(required) Email address(required) 1. How would you rate your smile? (5 being very pretty) 1 2 3 4 5 2. What would you like to change about your smile? 3. How much do you expect to pay for a bleaching? 4. What results do you expect to see after a bleaching? And how long would you be prepared to wait for optimum results? 5. Do you have any crowns or fillings in your smile line? Are you aware that they do not bleach? 6. Are you prepared to come for follow - up bleaching appointments? 7. How many cigarettes/ pipes do you smoke in a day? 8. How many cups or glasses of coffee, tea or red wine do you drink per day? 9. Can we take before and after photographs of your teeth to monitor your results and use as an example? 10. Do you suffer from sensitive teeth? 11. Does ice cream or cold drinks hurt your teeth when you have them? NB: Please be advised that your results will differ from the advertisement as it is only a product marketing tool. Type the characters(required) This field should be left blank Send Please wait... Please answer the following questions: Gender(required) Male Female First name(required) Surname(required) Cellphone number(required) Email address(required) 1. ILLNESSES: (Do you have or have you had any of the following) (A) Heart Disease: Coronary Thrombosis, Angina, Blood Pressure . Rheumatic Fever, Congenital Heart Disease? (B) Asthma, Bronchitis , Emphysema or any other lung disease? (C) Do you smoke? If so , how many? (D) Jaundice, hepatitis , liver disease? (E) Kidney disease? (F) Diabetes : (What treatment are you having?) (G) Epilepsy : (What treatment are you having?) (H) Arthritis? (I) Muscular disease? (J) Porphyria? (or any member of your family) (K) Bleeding tendency? (or any member of your family) (L) Allergies? (Including any i njections or medic i nes) 2. PREVIOUS OPERATIONS: (Specify) (A) Operations, Dates (Approx.) (B) Have you or any member of your family had any complications or unusual reactions to local or general anesthesia? (C) Do you have any artificial limbs? (e . g. knees , hips or heart valves) 3. MEDICATIONS: (Are you taking or have you taken) (A) Heart Drugs? (B) Cortisone or other steroids? (C) Blood pressure drugs? (D) Anti - coagulants, (" Blood thinners")? (E) Tranquilli s ers , sedatives, sleeping tablets or anti - depressant drugs? (F) Thyroid drugs? (G) Any other drugs (e . g. pa in tablets, contraceptive pills, antibiotics, etc . ) FEMALE PATIENTS Are you pregnant?(required) Yes No Do you use an oral contraceptive ( “ The Pill ” )? Yes No Please verify this information at each visit as it is important when taking X - rays and when prescribing antibiotics.DECLARATION: I declare tha t t h e above mentioned information is correct and that I shall make known any ch anges in my health to the treating doctor. I further declare that the abov e - mentioned address is the account hol der ’s permanent address ( domicilium citandi et executandi ). I accept responsibility for my account. If my account is not settled in full before 60 days, I take full response to settle all outstanding balances. I give consent to be treated by a dentist after consultation and with my full understanding the treatment plan. This is a legal and binding contract. Type the characters(required) This field should be left blank Send Please wait...
