Patient Registration Form : Laura Dental Center

Patient Registration Form

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Patient Information (Confidential)

We fully respect your right to privacy. Any personal information which you provide to us will be treated with the highest standards of security and confidentiality, strictly in accordance with the Data Protection Act.

Full Name *

Date of Birth *

Country of Residence *

Phone *

E-mail *

Passport No *

Home Address *

Dental & Medical History

Date of last dental visit? *

(Approx. month or year please)

Please place a mark on “Yes”or “No” to indicate if you have or have had any of the following:

Allergies *

Yes (explain)

Cancer *

Yes (explain)

Diabetes *

Yes (explain)

Heart Problems *

Yes (explain)

Epilepsy *

Yes (explain)

Sinus Problems *

Yes (explain)

Tooth Sensitivity *

Yes (explain)

Periodontal Disease *

Yes (explain)

Tooth Grinding *

Yes (explain)

Please place a mark on “Yes”or “No” to indicate if you are currently taking any prescription medications :

Blood Thinners *

Yes

Heart Medications *

Yes

If Yes, please list ALL prescribed and over the counter medications:

Are you pregnant? *

Yes (Week?)

How did you hear about us?

Social media

Google

Reference / Advice

TV / Radio

Other

Signature

Signature of Patient *

Reset Signature

Signature is required.

Personal Data Protection Authority Notice *

I agree to the storage, processing and transfer of the data in accordance with the matters specified in the PDPA Disclosure Notice. Click to read

Cookie Policy *

I accept the storage, processing and transfer of data in accordance with the issues specified in the Cookie Policy. Click to read

Consent Form *

I accept the storage, processing and transfer of the data in accordance with the matters specified in the Consent form. Click to read