Z.4. 16TEETH CONSENT DENTAL

New Patient Registration

and consent form
Permission.

Permission to share my health information through the Health Information Exchange System (NABIDH) in accordance with the United Arab Emirates legislation and Dubai Health Authority,and medical and dental authorities all over the world.
CLINIC'S CITY *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

DayMonthYear
Date
Name*

First NameLast Name
Date of Birth*

DayMonthYear
PHONE*

MOBILE PHONE 1MOBILE PHONE 2
MOBILE NUMBER*

Area CodePhone Number
MOBILE NUMBER

Area CodePhone Number
E-mail*
example@example.com
ID or Driver liscence or passport(FRONT PAGE)*

Cancelof
ID or Driver licence or passport(BACK PAGE)*

Cancelof
how you know us ?

InstgramYoutubeFriendsFacebook
Choose*

Teeth brushing 1 time dailySmokerCoffe or teaLiver , kidney , diabeticAllergy
IF YOU ARE TAKING ANY MEDICATION, HAVE ANY MEDICAL OR DENTAL PROBLEM OR ALLERY PLEASE LIST IT HERE?*

YesNo
If yes, please list it here*
by choosing (yes) I hereby allow Dr. Mostafa Osama Mahmoud and his businesses to post my videos and pictures on social media platforms and on any screen or billboard for the sake of using it for advertising for his business, I agree to all terms and conditions and i saw the video and photos and i approves posting it, also he can use it for life without any limits or conditions*

yesno
NOTES*
MENTION ANY NOTES HERE
DENTIST NAME*

First NameLast Name
DENTIST SIGNATURE

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TOTAL COST/المبلغ الاجمالي *
CLIENT'S Signature*

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Should be Empty:

New Patient Registration

Permission.