All your data will remain strictly confidential and will not be disclosed. If you have troubles filling out the form, we will always be happy to help and to assist you personally.
Name
Date of Birth
Email
Telephone
Country
City
The following information is very important for us in order to provide you with dental services in most effective and safe way in accordance with condition of your health. Insufficient and misleading information could do harm to your health. Please, answer all the questions. If you do not understand the question or you are unsure, discuss it with your doctor.
Your Weight
Your Height
Are you at present under observation of general doctor? YesNo
If «YES», specify the reason
Do you meet all medicines or products? YesNo
If «NO», please, specify each medicinal agent or product that caused undesirable reaction, and describe in short the consequences
Have you used local anesthesia previously (Novocain, Lidocaine or other), when it was for the last time and how did you meet it? (Did you feel weakness, excessive sweat, shortness of breath, faints or other sense of discomfort?)
If you know, specify figures of arterial pressure that is usual for you
Have you ever had any excessive bleeding requiring special treatment? YesNo
Are you on a special diet? YesNo
Do you suffer from oncological disease? YesNo
Blood Group Rhesus
Do you take treatment at present or did you take treatment previously from the following diseases? a. Heart disease (infarction, stenocardia, cardiac failure, other diseases): YesNo If «YES», specify them
b. Respiratory illnesses (chronic bronchitis, bronchial asthma, tuberculosis or other illnesses): YesNo If «YES», specify: what illnesses and what medical products you use for treatment
c.Digestive tract diseases (gastric ulcer or dodecadactylon or other): YesNo If «YES», specify: what illnesses and what medical products you use for treatment
d.Hepatopathy (jaundice, hepatitis): YesNo If «YES», specify: what illnesses and what medical products you use for treatment
e.Neuropathy (paralyses, convulsive disorder, faints or other): YesNo If «YES», specify: what illnesses and what medical products you use for treatment
f.Haemopathology (hemophilia, hypercoagulability, hemolysis, or other): YesNo If «YES», specify: what illnesses and what medical products you use for treatment
g.Endocrinopathy (diabetes, thyrotoxicosis, hypothyroidism, Basedow's disease, myxedema, Derbyshire neck or other): YesNo If «YES», specify: what illnesses and what medical products you use for treatment
How many times per year you have cold-related diseases?
When you were ill for the last time? Do you use antibiotics for treatment of these diseases: YesNo If «YES», specify what antibiotics and when did you use for the last time Do you have other problems with your health (specify something that is important to your mind)?
Have you used dentist's services previously? NoLess than 1 year agoLess than 5 year ago If yes, what type of dental treatment you had?
Short description of the dental problem now
Supposed terms of the treatment
Upload images - Panoramic X-Ray, Intraoral camera images, or Digital camera images - File type accepted: (pdf, png, jpg, jpeg). File 1 (Max size 2MB): FIle 2 (Max size 2MB): File 3 (Max size 2MB):
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