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Your First Appointment

* Name:

* E-mail:

Dental Health:

Why did you seek dental treatment:

Medical Health:

How is your general health?

Excellent Good
Fair Poor

Are you allergic or sensitive to any drugs or medicine (e.g. penicillin, aspirin)?

Yes No

Do you have or have you ever had any of the following problems?
 

Yes       No

Rheumatic fever

High blood pressure

Heart disease

Angina or chest pain

Heart murmur

Stroke

Anemia or blood pressure

Lung disease

Hay fever

Asthma

Allergies

Nervous disorder

Fainting spells

Diabetes

Arthritis

Cancer

Tumors or growths

Kidney disease

Seizure disorder

Stomach / intestinal (ulcers)

Liver disease

Thyroid problems

Sinus problems

Skin disease

Venereal disease

Herpes

A.I.D.S.

Hepatitis

Glaucoma

Women: Are you pregnant?

None of the above If Yes to any of the above please explain

Panoramic X-Ray 

For Implants patient
C-T Scan

I certify that the forgoing information is true and give my permission for any dental treatment

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Aleppo, Syria
Address: Franciscaine - Alrahman Mosque Circle
Tel: +963 21 2226408 / 2257520
Email:

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