Dental Evaluation Form



To get started with your FREE Dental Assessment, please complete the confidential form below.


Important Information:

  • A confirmed treatment plan can only be provided after a thorough examination by one of our dentists.
  • All cost estimates provided are based on the requested procedure and are subject to change.


We look forward to helping you achieve a healthy and beautiful smile!

Full Name
E-mail
Phone Number
Address
Birth Date
Gender
Body Weight (in KG's)
Height (in CM)
Emergency Contact name and number
What is the primary reason for today’s visit? (e.g., pain, routine check-up, specific treatment)
Are you experiencing any of the following dental symptoms? (Check all that apply)
Others (please specify)
Do you have Dentures?
Do you have any current dental treatments or restorations? (Check all that apply)
Other treatments (please specify)
Have you ever had any of the following dental procedures?
Other (please specify)
Do you have any of the following health conditions? (Check all that apply)
Other (please specify)
Are you currently taking any of the following medications?
Other medications
Do you have any known allergies? (Check all that apply)
Other allergies (please specify)
Do you smoke or use tobacco products?
If yes, how much?
Do you consume alcohol?
If yes, how often?
Do you use recreational drugs?
How much caffeine do you consume per day?
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เว็บไซต์นี้มีการใช้งานคุกกี้ เพื่อเพิ่มประสิทธิภาพและประสบการณ์ที่ดีในการใช้งานเว็บไซต์ของท่าน ท่านสามารถอ่านรายละเอียดเพิ่มเติมได้ที่ นโยบายความเป็นส่วนตัว and นโยบายคุกกี้
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