AguilarDentalClinicNewPatientForm

Name* This field is required.Pangalan

First Name

Last Name

Birthdate* This field is required.Kaarawan

Date

Age* This field is required.Edad

Address* This field is required.Tirahan

Street Address

City

Country

Mobile Number* This field is required.Selpon Number

Facebook Name/ Messenger NamePangalan sa Facebook/Messenger

First Name

Last Name

example@example.com

For Minors: Parent/ Guardian NamePangalan ng Magulang/ tagapag-alaga

For Minors: Parent/ Guardian's OccupationTrabaho ng magulang o tagapag-alaga

Date of Last Dental VisitPetsa ng huling pag bisita sa dentista

Are you in good health?Ikaw ba ay nasa malusog na kalagayan?

YESNO

Are you under medical treatment now?Ikaw ba ay kasalukuyang nag papagamot?

YESNO

If yes, what is the condition being treated?Kung oo, anong kundisyon ang ginagamot?

Have you ever had serious illness or surgical operation?Nagkaroon ka na ba ng kritikal na sakit o operasyon?

YESNO

If yes, what illness or operation?Kung oo, anong sakit o operasyon?

Have you ever been hospitalized?Ikaw ba ay na ospital na?

YESNO

If yes, when and why?Kung oo, kelan at bakit?

Are you taking prescription/ non-prescription medication?Ikaw ba ay may iniinom na gamot na nireseta/ o hindi nireseta?

YESNO

If yes, please specifyKung oo, paki lista ng mga ito

Do you use tobacco products?ikaw ba ay naninigarilyo?

YESNO

Do you consume alcoholic beverages?Ikaw ba ay nag iinom ng alak?

YESNO

Do you have any allergies to food or medication?* This field is required.Meron ka bang allergy sa pagkain o gamot?

YESNO

If yes, kindly specify allergens.Kung oo, paki lista ang pagkain o gamot na allergic ka.

Do you have or have you had any of the following? (choose which apply)Mayroon o nagkaroon ka ba ng mga ito? (Piliin kung alin mag-apply)

High Blood Pressure

Low Blood Pressure

Epilepsy/ Convulsions

AIDS/ HIV infection

Sexually Transmitted Infection

Stomach Troubles/ Ulcers

Fainting Seizure

Rapid Weight Loss

Radiation Therapy

Joint Replacement/ Implant

Heart Surgery

Heart Attack

Thyroid Problem

Heart Disease

Heart Murmur

Hepatitis/ Liver Disease

Rheumatic Fever

Hay Fever/ Allergies

Respiratory Problems

Hepatitis/ Jaundice

Tuberculosis

Swollen Ankles

Kidney Disease

Diabetes

Chest Pain

Stroke

Cancer/ Tumors

Anemia

Angina

Asthma

Emphysema

Bleeding Problems

Blood Diseases

Head Injuries

Arthritis/ Rheumatism

Other

Please be reminded that under Republic Act No. 1132 you are required to provide truthful information about your health condition and possible exposure to COVID-19. Non-cooperation is punishable by law.

Have you tested for COVID-19?* This field is required.Nakapag pa test ka na ba para sa COVID-19?

Yes, I tested positive

I have a scheduled date for a test/swab

Yes, but still waiting for results

Yes, I tested negative

No, never been tested for COVID-19

Yes, but I have recovered and is now negative

Have you had fever or other flu-like symptoms within the last 14 days?* This field is required.Sa loob ng 14 na araw na karamdam ka ba ng kahit anong sintomas na ito?

Fever (Lagnat)

Cough ( Ubo)

Runny Nose (Sipon)

Sore throat ( Namamagang lalamunan)

Shortness of breath ( Hirap sa pag hinga)

None, I dont have any symptoms (Walang kahit anong sintomas ng sakit)

Loss of sense of smell and taste (Pagka wala ng pang-amoy at panlasa)

Headache (Sakit ng ulo)

Muscle Pain (Masakit na kalamnan)

Diarrhea (Pag tatae)

Have you been in close contact with a COVID-19 positive, a person under investigation (PUI), a person under monitoring (PUM), or with someone who arrived from abroad or not from Albay within the last 14 days?* This field is required.May naka halubilo ka ba na PUI, PUM, taong galing sa ibang bansa or labas ng Albay sa nakalipas na 14 araw?

Covid-19 positive

PUI

PUM

Someone from abroad/not from Albay for the last 30 days

None

Have you visited any other country / region outside Albay within the last 14 days* This field is required.Lumabas ka ba ng Albay o ng ating bansa sa nakalipas na 14 araw?

Yes

If yes, kindly specify date and country/ regionKung oo, kelan at saan?

You may write any of your dental concerns here:Any treatment that you want to avail (Check up, Dental Certificate, Bunot, Pasta, Linis, Pustiso, Root Canal etc.) Any symptoms that you are experiencing etc.

Pls. choose preferred appointment dateThis is not yet final. We will VERIFY your appointment thru text. *CANCEL appointments 24hrs before scheduled day. *NO SHOW PATIENTS/ EXTREMELY LATE PATIENTS will be rescheduled after 2 weeks.

Date

Pls. choose preferred time slotThis is not yet final. We will VERIFY your appointment thru text. *CANCEL appointments 24hrs before scheduled day. *NO SHOW PATIENTS/ EXTREMELY LATE PATIENTS will be rescheduled after 2 weeks.

9am

1pm

3pm

Other

Do you need parking space?Kailangan mo ba ng paradahan?

YESNO

If yes, pls. indicate color and type of vehicle so that parking officers can assist right awayKung oo, ano ang kulay at klase ng sasakyan upang ma tulungan agad ng mga parking officers

Thank you for truthfully filling out our form.

We will contact you to verfiy your appointment with us.

See you soon in our clinic!

AguilarDentalClinicNewPatientForm