Step 1 of 4 25% Health Card NumberPatient DetailsJust to be sure, We have correct details right?HiddenValidator Patient Name First Last Patient PhonePatient Address Street Address Address Line 2 Age Patient Medical History DetailsDo you have any chronic medical conditions? No. All is well. Diabetes Hypertension Heart Disease Asthma Any Other? Please Specify What chronic medical condition you have? Have you ever had surgery? No Yes Surgery Type? Tell us about what surgery you went through?When?In this Month1 Month Ago2 Months Ago3 Months Ago4 Months Ago5 Months Ago6 Months Ago12 Months Ago18 Months Ago24 Months Ago2+ YearsTell us when you underwent this surgery?Are you currently taking any medications? No Yes, I have prescription Yes, I don't have prescription Upload Prescription Drop files here or Select files Max. file size: 40 MB. Have you ever had any allergies to medication or food? No Yes Please specify medications or food you're allergic to? Have you ever had any hospitalizations or serious illnesses? No Yes Please specify any hospitalisations or serious illnesses? Patient Dental History DetailsWhen was your last dental check-up?In this Month1 Month Ago2 Months Ago3 Months Ago4 Months Ago5 Months Ago6 Months Ago12 Months Ago18 Months Ago24 Months Ago2+ YearsTell us when you visited your dentist?Do you currently have any dental problems or concerns? If yes, please specify: No Yes Please specify your current dental problems or concerns? Have you ever had any dental procedures such as fillings, root canals, or extractions? If yes, please specify: No Yes Have you ever had any dental procedures such as fillings, root canals, or extractions? If yes, please specify: No Yes Please specify dental procedure you had earlier? Filling Root Canals Extractions Teeth Cleaning Any Other? Have you ever experienced any pain or discomfort in your teeth, gums, or jaw? If yes, please specify: No Yes Choose the orthodontic treatment you had? Braces Aligners Lifestyle & HabitsDo you smoke? No Yes Do you consume alcohol? No Yes Do you exercise regularly? No Yes Do you follow a healthy diet? No Yes Do you have any habits that may affect your dental or overall health, such as nail-biting or teeth-grinding? No Yes