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First Name
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Surname
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Email
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If the patient is child (Less than 16 years of age) please mention the guardian or parent details
What's your parent detail?
parent/Guardian Name
What's your parent name?
DOB of the patient
What's your patient DOB?
Age
What's your patient age?
Address
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Telephone number
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Telephone number
What's your telephone number2?
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Reason for seeking dentist -
Problem
Yes
No
Back pain
Fever
Normal check up
High blood pressure
Diabetes
Dental problem / tooth ache
Jaw pain/Joint pain
Wisdom tooth
Other (please specify)
Have you had any Any serious hospitalization, operations or serious issue in the last 5 years
Yes
No
What's your parent address?
If yes please write down the name and time that was diagnosed Please mark yes if you having following conditions
Mark if you have any of the below conditions before -
Problem
Yes
No
Breathing problem (Asthma)
High blood pressure
Fever /Cough
Diabetes
Heart problems
Kidney problems
Bleeding problems
Epilepsy (Fit)
Gastro intestinal problem
Other
Weight
What's your Weight ?
Height
What's your height ?
Blood group
What's your blood group ?
Smoking
Frequency – how much per day /Number of cigarettes per day
How long
Alchol
ferquency
daily water
Cholesterol
What's your Cholesterol?
Blood sugar
What's your blood sugar?
Blood pressure
What's your Blood pressure ?
Heart Rate
What's your Heart Rate?
upload /Write down medication/Drugs currently on
What's your Drugs ?
X ray and Radilogy views
What's your radilogy views ?
'If you want to send your pictuers to dentist please upload the pictuers Instructions on how to get pictures
please see before uploading
image1
What's your image1?
image2
What's your image2?
image3
What's your image3?
image4
What's your image4?
image5
What's your image5?
image6
What's your image6?
image7
What's your image7?
image8
What's your image8?
Username
What's your username?
Mobile Number
Sri lanka
+94
Nepal
+977
Bangladesh
+880
Australia
+61
What's your mobile no?
Password
What's your password?
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