Registration

If you wish to make an appointment with our dental team, you can complete the form below as fully as possible and submit it to us. It also assists us to assess your suitability for a procedure if you can provide any past dental records, dental x-rays or photographs of your teeth. Whilst these records are not essential, they do assist our dentists in recommending the best treatment for you. Please also refer to the webpage www.dental-phuket.com/photographs on which photos are suitable. Download Registration Form

PERSONAL INFORMATION

Title Name :	-- Title Name -- Mr Mrs Miss Ms  *
First Name :	*	Last Name :	*
Gender	Male   Female    *	Date of birth :	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  / January February March April May June July August September October November December  / 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Country :	-- Select Country -- AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS CONGO COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FEDERATED STATES OF MICRONESIA FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAQ IRELAND ISLAMIC REPUBLIC OF IRAN ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PUERTO RICO QATAR REPUBLIC OF KOREA REPUBLIC OF MOLDOVA REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT KITTS AND NEVIS SAINT LUCIA SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN THAILAND THE DEMOCRATIC REPUBLIC OF THE CONGO THE FORMER YUGOSLAV REPUBLIC OF MACEDONIA TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED REPUBLIC OF TANZANIA UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA YEMEN ZAMBIA ZIMBABWE   *
Phone :
Mobile :	*	Fax :
Email :	*
Address :	*

MEDICAL CONDITIONS (are you suffering from any of the following conditions, please indicate YES or NO)

Diabetes or blood sugar iregularities	Yes	No
Cardiovascular/Heart problems	Yes	No
High blood pressure	Yes	No
Blood disorders/Blood clotting	Yes	No
HIV or AIDS	Yes	No
If you have answered YES to any of the above, please specify:
Do you have or have you had any other medical conditions not mentioned above?	Yes	No
If yes, please specify:
Have you had any previous dental procedures that you were not satisfied with?	Yes	No
If yes, please specify:
Did you have any complications with this previous dental work?	Yes	No

WOMEN

Do you take birth control pills, hormone replacement medication or wear a hormone patch?	Yes	No
Are you pregnant?	Yes	No

MEDICAL HISTORY

Have you been hospitalised, had surgery or received medical carewithin the last 12 months?	Yes	No
If yes, when and what for?

Do you have any allergies to food, medication, herbs etc.?	Yes	No
If yes, when and what for?

Do you smoke? If yes, how many per day?	Yes	No

Do you drink alcohol? If yes, how many drinks (on average) per day?	Yes	No

Do you have or have you had any other medical history that your dentist should be aware of?	Yes	No
If YES, please specify:

STEP 2: DENTAL CONCERNS

Please select problematic teeth on the picture and make any remark here.	TOP: Select 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28	BOTTOM: Select 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
If you have multiple problematic teeth, please enter the numbers in the box below as well as any explanation

PHOTOGRAPHS REQUIRED FOR ASSESSMENT
Please provide photos of your teeth.

Type the code shown :		*