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MedAsia Healthcare Complex

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PERSONAL INFORMATION

Complete this confidential form for your FREE Dental Assessment from one of our board certified dentists.

Please note: In many cases an OPG Xray will be required for a quote to be sent. We will inform you if this is the case. We have several centres that you can visit for this x-ray.

*A confirmed treatment plan can only be provided at the time you are examined by the Dentist. All quotations provided are estimated costs of the procedure requested. All estimates given are subject to change.

PERSONAL INFORMATION

Full Name (As Appears On Your Passport) * First Name Middle Name Last Name
Birth Date * Day Month Year
Phone Number *
E-mail *

Current Address *	Street Address
	Street Address Line 2
	City	State / Province
	Postal / Zip Code	Country

Gender *
Male Female Transgender
Nationality *
Preferred Language *

PERSON TO CONTACT IN CASE OF EMERGENCY

Full Name * First Name Last Name
Relation To You *
Phone Number *
E-mail *

Current Address	Street Address
	Street Address Line 2
	City	State / Province
	Postal / Zip Code	Country

PROCEDURE INFORMATION

What Procedures Do You Require? Please be specific. * E.g. Porcelain veneers, dental implant etc.
What Results Do You Want To Achieve? * E.g. Straight teeth, no overbite etc.
Fly In Date (If Known) Day Month Year
Fly Home Date (If Known) Day Month Year
Do You Have Any Questions For The Dentist?

YOUR MEDICAL HISTORY

Do you have any medical conditions? If YES, Please provide details * Please provide as much detail as possible
Have you had any surgery in the last 5 years? If YES, please give details * Please provide as much detail as possible
Do you have any allergies to food, drugs etc? IF YES, PLEASE GIVE DETAILS * Please provide as much detail as possible
List all medications you currently take, the dosage you take for each and why you are taking this medication. * Please provide as much detail as possible
List all vitamins or food/nutritional supplements you currently take and dosage. * Please provide as much detail as possible
Do you currently have cancer? Or have you previously had cancer within the past 2 years? If YES, please give details * Please provide as much detail as possible
Do You Smoke? *
Yes No
If You Answered YES, How Many Cigarettes Do You Smoke Per Day?
Do You Drink Alcohol? *
Yes No
If You Answered YES, How Many Alcoholic Beverages Do You Consume Per Week?

YOUR PHOTOS + FINAL STEPS

Your photos are an important part of your free assessment from the Surgeon. Please follow the Photo Guidelines. If you have trouble uploading photos with this form, please email them direct to your consultant or enquiries@medimakeovers.com.

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Do you have an OPG xray, or any xrays? *
Yes No
Is there any other information that you would like to share with us?
I declare that I have truthfully completed the entirety of this form and that I have not made any purposeful omissions. * Yes, I agree / Understand

PERSON TO CONTACT IN CASE OF EMERGENCY
Full Name *
First Name Last Name
Relation To You *
Phone Number *
E-mail *

Current Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

PROCEDURE INFORMATION
What Procedures Do You Require? Please be specific. *
What Results Do You Want To Achieve? *
Fly In Date (If Known)
Day Month Year
Fly Home Date (If Known)
Day Month Year
Do You Have Any Questions For The Dentist?

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