Patient Registration
SHALASH DENTAL & IMPLANT CENTER
File code
— Based on the first letter of the name — e.g. Ahmed → A1, another Ahmed → A2, Nourhan → N1
Name
Birth Date
Age
Sex
Marital Status
Home Address
E-mail Address
Cell Phone
Home Phone
Work Phone
Occupation
Employer
Nationality
Emergency Contact: Name
Relationship
Phone No
How did you hear about our office?
Friend (Please specify):
Other (please specify):
Health Status:

We take Your Health very seriously. Before we start treatment we need some information. Your medical history may affect your dental treatment.

  • Have you ever been hospitalized? Y N
  • Have you ever had a blood transfusion? Y N
  • Are you taking any medications at the moment? Y N
  • Do you have any allergies to any medications? Y N
Females Only
Are you pregnant? Y N
Are you nursing? Y N
Oral Contraceptives Y N

I certify that I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge.

Payment Policy:
Payment is due in full at time of treatment, unless prior arrangements have been approved.
Signature:
Date: