Welcome to the "Center for Dental Restoration"
To ensure a high-quality and comfortable reception, please fill out a short questionnaire
To ensure a quality and comfortable reception, please fill out a short questionnaire
1. Full name
2. Date of birth
3. Specify your current address
4. Your contact phone number
Just enter digits of your number, additional characters will appear themselves
5. Your e-mail address
Access to the patient's personal account will be sent to the e-mail address you provide
6.
How do you prefer to communicate with the center:
Telegram
Viber
WhatsApp
Phonecall, sms
Facebook, Instagram
E-mail
7.
Is the reason for the visit related to acute pain?
Yes
No
8.
Have you had an X-ray examination in the last 6 months?
*According to the rules of the Center, you are required to undergo an Rtg examination for a full and high-quality consultation and treatment.
9.
Are you currently taking medication?
10.
Do you have children?
11.
Do you have allergic reactions to:
Antibiotics
Anesthetics
Medicinal agents
Iodine
Latex
Food products
Household chemicals
Other allergens
No allergic reactions
12.
Do you have any of the following conditions:
Heart disease
Blood pressure disorders
Neck or back pain
Arthropathy
Sinusitis
Thyroid dysfunction
Asthma
Захворювання дихальних шляхів
Respiratory tract diseases
Diabetes
Blood clotting disorders
Epileptic seizures
Hepatitis, liver disease
HIV/AIDS
Panic attacks, feelings of anxiety
Pregnancy
13.
How have you felt emotionally over the past month:
14.
How do you rate your physical activity during the week:
15.
How much water do you consume during the day:
до 1 літра
1 - 2 літра
більше 2 літрів
16.
How would you rate the condition of your gastrointestinal tract:
10
9
8
7
6
5
4
3
2
1
17.
How would you rate the quakity of your sleep (where 1 is not at all rested, 5 is fully rested):
18.
How would you rate your level of inner energy:
19.
How did you find out about us?
Outdoor advertising
Google search
USC
Recommendations from friends
20.
Agreement to the terms of service
I agree with the terms
* By filling out this form, I confirm the accuracy and absolute correctness of all the above personal data. I understand that the gathering, processing, use and storage of such data by the clinic staff does not violate my rights and legitimate interests, including those provided for by the Law of Ukraine “On Personal Data Protection” of June 1, 2010. No. 229. I provide data about my identity (the identity of my child, ward or principal) personally and allow the staff and administration of the clinic to process, use and store them for the preparation of medical, information, legal and other documentation, entry into information, client databases, etc. in cases where it is necessary and/or related to my medical care or registration of legal relations. I agree to take photos and videos of me (my child) at all stages of treatment and understand that this is necessary in order to provide qualified dental care, and also allow them to be used for demonstration, scientific, advertising and educational purposes. I, as a patient, am warned that in case of providing inaccurate, inaccurate or incomplete information, all negative legal and other consequences are my responsibility. I understand that in the course of medical care, it may be necessary to collect additional personal data, so I do not object to this in compliance with the requirements of the current legislation. I have read the Regulations on warranty obligations when providing dental services of "Simetrika" LLC. I have read the public offer agreement for the provision of medical dental services and accept its terms.
