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Registration formBleaching formMedical history form

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Email address(required)

1. How would you rate your smile? (5 being very pretty)

3. How much do you expect to pay for a bleaching?

5. Do you have any crowns or fillings in your smile line? Are you aware that they do not bleach?

7. How many cigarettes/ pipes do you smoke in a day?

9. Can we take before and after photographs of your teeth to monitor your results and use as an example?

11. Does ice cream or cold drinks hurt your teeth when you have them?

2. What would you like to change about your smile?

4. What results do you expect to see after a bleaching? And how long would you be prepared to wait for optimum results?

6. Are you prepared to come for follow - up bleaching appointments?

8. How many cups or glasses of coffee, tea or red wine do you drink per day?

10. Do you suffer from sensitive teeth?

NB: Please be advised that your results will differ from the advertisement as it is only a product marketing tool.

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Gender(required)

Cellphone number(required)

First name(required)

Email address(required)

Surname(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?

(C) Do you smoke? If so , how many?

(E) Kidney disease?

(G) Epilepsy : (What treatment are you having?)

(I) Muscular disease?

(K) Bleeding tendency? (or any member of your family)

(B) Asthma, Bronchitis , Emphysema or any other lung disease?

(D) Jaundice, hepatitis , liver disease?

(F) Diabetes : (What treatment are you having?)

(H) Arthritis?

(J) Porphyria? (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?

3. MEDICATIONS: (Are you taking or have you taken)

(A) Heart Drugs?

(E) Tranquilli s ers , sedatives, sleeping tablets or anti - depressant drugs?

(G) Any other drugs (e . g. pa in tablets, contraceptive pills, antibiotics, etc . )

(B) Cortisone or other steroids?

(D) Anti - coagulants, (" Blood thinners")?

(F) Thyroid drugs?

FEMALE PATIENTS

Are you pregnant?(required)

Do you use an oral contraceptive ( “ The Pill ” )?

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.

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Person Responsible for Account

Medical Aid

Nearest Family

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Family Details

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FEMALE PATIENTS