Patient History Form

Patient History Form
Welcome to Dental Designs Clinic. We’re delighted to have you with us. To ensure we provide you with the highest standard of dental care, we’ll need to collect some personal information and details from you.

Your privacy is important to us, and we assure you that the information collected will be used only for the purpose of addressing accounts to you, processing payments, and keeping you informed about your treatment. If you have any questions, please don't hesitate to reach out to us.

- The Dental Designs Team
Title

MrMrsMsDoctor
Name (as per ID)*

First NameSurname or Last Name
NRIC / FIN*
Date of Birth*
Mobile Number (For Calls & WhatsApp Messages)*

CountryPhone Number
Emergency Contact Phone Number:

CountryPhone Number
My WhatsApp number is different from my local mobile number
WhatsApp Phone Number

CountryPhone Number
Email*
We will be sending emails with essential information about your treatment, including care instructions, consent forms, follow-up details, and appointment reminders.
Address *
Postal Code*
Company
Occupation
Will you be using any Dental Insurance? If so, please state the name
To process your claims, we require you to inform us before you see the dentist. Failure to do so will result in billing under our standard rates.
Would you like to be contacted for regular recalls?

YesNo
Dental History
When was your last Dental Appointment?*
How many months ago were your Dental X-rays taken?*
From a scale of 1-5, how nervous are you about Dental Treatment?*
Other Area of Concern?

NoneBad Appearance of TeethBad BreathBleeding GumsLost Filling/CavityMissing TeethSensitive TeethToothacheDiscoloured Teeth/ Interest in WhiteningWorn, Broken TeethWisdom TeethOther
Medical History
Medical History - Please select all that applies to you

Abnormal BleedingHerpes/ Cold SoresHepatitis ADiabetes Type 1Artificial Heart ValveHepatitis BDiabetes Type 2Cardiac Surgery/PacemakerHepatitis CEpilepsyRheumatic Heart DiseaseHIV PositiveEating DisorderHeart ConditionsRadiation Theraphy/ ChemotherapyOthers
Are you or have you been a smoker?

NoYes
Do you snore or experience restless sleep?

NoYes
Are you taking any medications?*

NoYes, Warfarin MedicationYes, Bisphosphonates (e.g. Fosamax)Yes - Please List:
Allergies:*

No Known Drug AllergiesAspirinSulpha DrugsPenicillinNSAIDsLatexOther
For Females Only

Letting us know if you're pregnant or breastfeeding allows usto personalise your care and avoid anything that may affect you or your baby.
Are you expecting?

NoYes
If Yes - please specify estimated due date:
Are you breast feeding?

NoYes
How did you hear about us?*

Saw our clinicWebsiteGoogle SearchFacebookInstagramXiaohongshu (小红书)PodcastPreferred Insurance ProviderCompany RecommendationFriend Referral - If so, who?
I have completed the above to the best of my knowledge, and all information collected will be treated confidentially. I acknowledge that I have read and understood the information provided in this registration form. I consent to the collection and use of my personal and medical information by Dental Designs Clinic for the purposes of my treatment and care.

I also consent to receiving treatment-related information, appointment reminders, and marketing emails about new services, promotions, and educational content from Dental Designs Clinic. I understand that I may opt out of receiving marketing communications at any time by following the unsubscribe instructions provided in the emails.
Patient/Guardian Signature*

Clear
Date

DayMonthYear
Date
Would you like to have more information regarding:

Teeth WhiteningMouth GuardsStraightening of TeethGuided Dental ImplantsSame Day Crowns (CEREC)Cosmetic Dentistry
Are you taking any medications?*

NoYes
If yes, please list:
Friend Referral? If so, who?
Reason for today's visit*
Should be Empty:

Patient History Form

Dental History

Medical History

For Females Only