Patient Registration

30/11/2020

    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