🖥️ XRAY Patient Only

🏠 Taguig Branch

X-ray only: After you submit, you will appear on the clinic's X-Ray Requests list only. You will not receive a doctor queue number.

Personal Information

Full Name *

Nickname

Birth Date *

Format: MM/DD/YYYY — or use the calendar

Age *

Auto-calculated from birth date

Gender *

Marital Status *

Address *

Contact Number *

Guardian Name / Contact *

Occupation *

Medical History

Please answer YES or NO to the following questions.

Are you in good health?

Yes No

Do you have regular check-up?

Yes No

Have you been hospitalized?

Yes No

Do you bruise easily?

Yes No

Heart Problem?

Yes No

Low / High Blood Pressure?

Yes No

Diabetes?

Yes No

STD?

Yes No

Asthma?

Yes No

Cancer?

Yes No

Epilepsy / Seizure?

Yes No

Are you taking any medications?

Yes No

Do you have any allergies?

Yes No

Other Medical Conditions:

For Women Only (Optional)

Are you pregnant?

Yes No

Are you breastfeeding?

Yes No

Are you taking birth control pills?

Yes No

X-Ray Notes (optional)

Shown on the X-ray requests page for staff.

HEALTH DECLARATION: I understand the importance of a truthful health history and that my dentist and her staff will rely on this information for treating me. I will not hold my dentist and her staff responsible for any action they take or do because of errors that I may have made in completion of this form.

INFORMED CONSENT: I have been given the opportunity to ask questions regarding the proposed treatment and have received answers to my satisfaction. I understand and assume all risks associated with the procedure. I am freely giving my consent to allow and authorize Dr. and her associates to render treatments including any anesthetics or medications. I am willing to pay all necessary services rendered to me.

Patient / Guardian Signature *

Opens a large signing area for pen tablets

Witness Name

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