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
you have any general condition?
heart disease, diabetes melitus, hepatitis, HIV, ephylepsia
you take any medication? Explain
you have any alergies? If yes, explain
all major injuries, surgeries and/or hospitalizations you
you have any accidents after tooth extraction? Explain
you have any accidents after anesthesia? Explain
Describe your dental problems
this form and then upload your Xrays