Patient Registration

05/07/2020

Kindly provide your Emirates ID, insurance card, and any other discount cards



MaleFemale








How Did You Hear About Us ?

Visual Pain Scale





No Pain
Moderate Pain
Worst Possible Pain

Smile Assessment

Are you pleased with the general appearance of your teeth and smile ?

YesNo

Medical History

Have you had any of the following :

Heart or heart valve problem

YesNo

High blood pressure

YesNo

Haemophilia or prolonged bleeding

YesNo

Asthma

YesNo

Diabetes

YesNo

Epilepsy

YesNo

Hepatitis or HIV

YesNo

Liver, kidney or thyroid problems

YesNo

Serious illnesses or operations

YesNo

Heart surgery

YesNo

Other medical problems

YesNo

Do you have allergies to ?

Any other allergies ?

YesNo

Are you taking any medication ?

YesNo

Do you smoke ?

YesNo

Are you pregnant

YesNo

Have you ever had any serious trouble associated with dentistry ?

YesNo


1) Do you have the following signs and symptoms ?

Cough

YesNo

Fever

YesNo

Shortness of breath

YesNo

Runny nose

YesNo

Pain - throat/head/body

YesNo

Vomitting / diarrhea

YesNo

Feeling generally unwell

YesNo

2) Have you travelled to China, Japan, Hong Kong, South Korea, Iraq, Singapore or Italy in the last 28 days ?

YesNo

3) Have you cared for or come into contact with an
individual known or strongly suspected to have
CoronaVirus within last 28 days ?

YesNo


Note: if your answer is yes to either No.1 or No. 2, along with any of the signs and symptoms please ask for mask from the reception. You will be assisted to the isolation room while waiting for the doctor to see you for further assessment and management