SC-Updated Pediatric Registration Form-2021

  • Pediatric Registration Form

    Please fill in the form below
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  • Proof Of Identity*

  • Would you like to be reminded about your next appointment?*
  • If yes, please select the mode of reminder*

  • How did you hear about our clinic? Please chose from the following options*

  • Pediatric Medical Information

  • Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements?*
  • Has your child ever had a reaction to or problem with an anesthetic*
  • Is your child allergic to latex or anything else such as metals, acrylic or dye?*
  • Does your child suffer from any disease from the following? (Select all that apply)*
  • Does your child have a history of any of the following?*
  • Sucking habit after one year of age*
  • If yes, which:
  • How often does your child floss his/ her teeth?*

  • How frequently does your child have the following?

  • Snack between meals?*
  • Candy or other sweets?*

  • Soft drinks?*

  • Has your child received treatment from another dentist?*
  • Were x-rays taken of the teeth or jaws?*
  • Has your child ever had a difficult dental appointment?*
  • How do you expect your child will respond to dental treatment?*

  • Consent to NABIDH

  • The NABIDH HIE is a medium that allows your health information to be shared by participating providers including medical groups, hospitals, labs, radiology centers, and other health care providers through secure, electronic means.

  • I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies

  • Participation is voluntary and will not affect your ability to receive medical care. If you optout, the NABIDH will block access to your health information even for emergency treatment.


    This means that it may take longer for your healthcare providers to get the medical information they may need to treat you. Even if you do not want to participate in NABIDH, Emirate of Dubai law reporting requirements will still be fulfilled through Public Health Registries and research. This means your health information will be used anonymously

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