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Step 1/2

Please fill this form and you will receive a complete offert for your high quality dental treatment.

This is a preliminary medical form and all the informations are confidentials.

Name:
Adress:
City:
Zipp Code
Country
Telephone
Fax
Email

Medical history

Date of birth (dd/mm/yyyy)
Gender

Do you have any general condition?
(eg. heart disease, diabetes melitus, hepatitis, HIV, ephylepsia etc.)


Do you take any medication? Explain

 

Do you have any alergies? If yes, explain

 

List all major injuries, surgeries and/or hospitalizations you have had:

 

Do you have any accidents after tooth extraction? Explain

(eg. bleeding, etc)

 

Do you have any accidents after anesthesia? Explain

 

Describe your dental problems

   

Send this form and then upload your Xrays
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