Dental Record Chart

Your Full Name *

Note: If you don't follow instructions (e.g. incomplete full name), it will be not entertained or automatically refuse to consultation

Birthdate *

Age *

Sex *

Male

Female

Contact Number *

Email Address *

We’ll send your dental certificate and prescription to this email address — make sure it’s correct!

Full Address *

Medical History

Any Medical History? (Please State below for reference) *

if nt applicable please put N/A

Any Allergies? *

if nt applicable please put N/A

Dental History

Chief Complaint (Your main concern) *

Please use the Image below as your reference (e.g. i have tooth ache and cavity on tooth #12); Please be specific on what tooth you concern.

Last Dental Visit *

Put N/A if not applicable

Last Dental Procedure Done *

Put N/A if not applicable

Do you need dental certificate? *

Yes

Is this for? *

Fit-To-Work (Included)

Excuse (Included)

Dental Clearance/Certificate (Included)

For Consultation only

Others

How many days (for excused) *

N/A if not applicable

If it is excused, what is the reason?

Note: reason must be valid or true or else, it will be subjected to rejection of your dental certificate.

Excuse from what date?

e.g, From Jan 1 to 2

Optional

Panoramic X-ray

Leave it if you don't have

Clinical Picture/Image

Picture of your mouth/teeth invloved/proof of your main concern if you have

Dental Record Chart From Previous Clinic - this is required for dental clearance

I hereby acknowledge and consent to the terms and conditions set forth by the company. I affirm that all the information provided above is accurate and authentic.

I hereby consent and acknowledge that if any of the information provided is found to be false, inauthentic, or incorrect, I shall not be held liable in any manner. Such information shall be automatically deemed invalid and without effect, and any related matters shall be subject to legal review and adjudication in a court of law.

Signature (Input your name as E-signature) *

Clear