Dental Patient Information

General Patient Information
Welcome!

This is an Online Patient Information Form.

1. Fill out the questionnaire.

2. Review your answers. Make sure all required information were given.

3. The Informed Consent, Guidelines and Protocols are provided in the latter part of the form. Please thoroughly read it, so as to be informed with new clinic's Standard Operating Protocol.

4. Click "Submit".

* Required
Take Photo*
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Age:*
Patient Gender*
Contact Number*
Please enter a valid phone number.
Patient E-Mail*
example@example.com
Nature of Dental Complaint or Concern:*
Yes,I am the PatientNo, I am the Parent/GuardianNo, I am the Companion
Patient Medical History
Yes, Fully vaccinated1st DoseNoBooster
Do you have any known allergies? (food or drug allergies) if yes, please specify*
AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:*
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.*
Acknowledgment, Authorization and Waiver
1. I authorize PRODENT ADVANCED ORAL HEALTH to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.
2. I confirm that the dentist explained the procedure thoroughly to me and how it will help me with my current condition.
3. I authorize the use of anesthesia and understands the side effects I can experience from it.
4. I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
5. I understand that I am not allowed to drink alcohol 24 hours before the procedure. (for surgery)
6. I acknowledge that all information I provided in this form is true and accurate.
7. I understand that regardless of any dental insurance that I have, I am responsible for payment of my dental fees.
I Agree
Patient/Parent/Guardian Signature*

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Date Signed*

MonthDayYear
Date
GUIDELINES AND PROTOCOLS

1. STRICTLY BY APPOINTMENT. Only those with appointments for the day shall be accommodated. Appointments may be pre-scheduled thru the following:

Google page: https://prodentadvancedoralhealth.business.site
E-mail: prodentadvanced@yahoo.com
Mobile number: +63 922 888 1180
Landline: (032) 383 9372

2. Please come on time for your appointment to avoid the overlapping of patients.

3. Please call or text at least one day before your appointment if you are not available for your schedule.

Thank you for your cooperation, and we are looking forward to seeing you again!
Should be Empty:

General Patient Information

Patient Medical History

Acknowledgment, Authorization and Waiver