Patient Registration Form · Laura Dental Center

01

Patient Information (Confidential)

We fully respect your right to privacy. Any personal information which you provide to us will be treated with the highest standards of security and confidentiality, strictly in accordance with the Data Protection Act.

Full Name * Date of Birth * Country of Residence * Phone * E-mail * Passport No * Home Address *

02

Dental & Medical History

Please answer accurately so we can plan your treatment safely.

Date of last dental visit? (Approx. month or year please) *

Please place a mark on “Yes”or “No” to indicate if you have or have had any of the following:

Please place a mark on “Yes”or “No” to indicate if you are currently taking any prescription medications :

Blood Thinners *

No Yes

Heart Medications *

No Yes

Are you pregnant? *

No Yes (Week?)

If Yes, please list ALL prescribed and over the counter medications: Optional

03

Contact and consents

Read and approve the required notices before the final step.

04

Signature

Signature of Patient *

Sign in the area below using your finger or mouse.

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