Dental Assessment Form

Patient Details

Patient's First Name *

Patient's Last Name *

Patient's Email *

Patient's Phone Number *

Patient's Date of Birth

Patient's Country *

Requested Dental Treatment

If Other, please specify

Current Dental Concerns

Medical History

Do you smoke cigarettes, vape, or smoke marijuana? Please tick all that apply.

If Other, please provide details

Do you have any allergies?

Yes

No

If yes, please provide allergy details

Are you currently taking any medications?

Yes

No

If yes, please list medication, dose, frequency, and reason

Are you pregnant or breastfeeding?

Yes

No

N/A

Are you taking blood-thinning medication?

Yes

No

Do you grind or clench your teeth?

Yes

No

Unsure

Dental Records and Uploads

Which files are you uploading?

Dental photos / teeth photos

OPG / dental X-rays

CT scan

Previous dental plans or records

Please tick all file types included in your upload.

Need help taking your teeth photos? View the dental photo guide here.

Upload dental photos, OPG/X-rays, CT scans or previous dental records

Upload all available files here. You can submit the form even if you do not have an OPG/X-ray yet.

Travel Details

Preferred Travel Timing

Have you already booked travel?

Yes

No

If travel is booked, please provide details

Consent

I confirm that the information provided is accurate and I agree to the Terms & Conditions.