Patient Registration

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

    MaleFemale

    How Did You Hear About Us ?

    Visual Pain Scale

    How much pain are you in?

    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

    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

    Have you ever had any serious trouble associated with dentistry?*

    YesNo

    Do you smoke?*

    YesNo

    Are you pregnant?*

    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

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