Online Form

Online Form 2018-05-18T19:20:07+00:00

Please Fill This Online Form

Thank you for selecting our dental team! We will strive to provide you with the best possible dental care.

Although we primarily treat the area in and around the mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions honestly and completely.

  • Patient Information
  • Dental History
  • Medical History
  • Women
  • Allergies

Patient Information

Date

Name

Address

DOB

Age

Sex

Marital Status

Nationality

State of Origin

Religion

Home Phone

Cell Phone

Email Address

Are you a Student?

Name of School/College

City

State

Employer Details

Employer

City

State

Phone

Emergency

Emergency Contact

Home Phone

Cell Phone

Next of Kin

Name

Address

Phone

Relationship

If Minor, Head of Family

Surname

First Name

Tel No

Payment

Please Give Details

Name of Company

Address

Tel No

Name of Insurance Company

Address

Tel No

Fax No

Policy No

Registered address with the insurance company

Whom may we thank for referring you?

Dental History

Date of Last Dental Care

Date of Last Dental X-Rays

Former Dentist Name

Are you having or have you had any of the following

Are you having or have you had any other concerns with your mouth and/or teeth?

How do you like your smile? Rate you smile

What, if anything, would you change about your smile?

Would you like more information on

Other

Medical History

Physician's Name

Date of Last Visit

How long ago was your blood pressure checked?

Approximate Reading

Phone

Are you on a special diet?

If yes, explain

Do you have any or have you ever had any of the following

Heart disease/Heart surgery

Kidney disease/Kidney surgery

High blood pressure/Hypertension

Gastric/Peptic ulcer

Diabetes

Sickle Cell Anaemia

HIV

Hepatitis

Cancer/Tumor/Groth

Radiotherapy/Chemotherapy

Any bleeding disorder

Any Other

Women

Are you trying or trying to get pregnant?

Taking oral contraceptives?

Nursing?

Allergies

Allergies

Other

List all prescription drugs you currently take

List any Herbal Remedies, Multi-Vitamins, Supplements or Over the Counter Drugs you take more than 2x per week

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my [patient's] health. Is my responsibility to inform the dental office of any change in medical status.

Date

The First 7 Day Dental Practice in Africa. Available in both Victoria Island and Ikeja, 7 Days a Week.