Do you smoke, If yes, how many?

Are you Pregnant, If yes Due Date

What is the reason for your visit today?

Are you aware of grinding or clenching your teeth?

Are you ever troubled with ‘Bad breath’?

Has the fear of discomfort kept you from having regular dental care?

Are you self- conscious about the appearance of your teeth?

How long since your last through dental exam?

Have your wisdom teeth being removed?

Do your gums ever bleed or feel tender?

Do you use dental floss?

Have you ever had a difficult extraction or experienced prolonged bleeding?

Consent for Treatment

I hereby authorize the dentist or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate to make a through diagnosis.

Upon such diagnosis, I authorize the dentist or designated staff to perform all recommended treatment mutually agreed upon by me and employ such assistance is required to provide proper care.

I agree to the use of anaesthetics, sedatives and other medications as necessary. I fully understand that using anaesthetic agents embodies certain risks. I can ask for complete recital of any possible complications.

I acknowledge that in case of any medical/ dental record enquiries, there will be an associated, non refundable, processing fee as per the current terrif.

I give consent to share my medical records when it has been deemed necessary to seek an external professional advice, opinion or for referral purposes.

I am the responsible person for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

I acknowledge that a 24 hours notice is required to cancel or reschedule my dental booking. A short notice or absence without notice will arise a cancellation fee as per current tariff.

Date.............. Patient’s signature..............

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