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Dental recovery center

Welcome to our clinic!

1. Full name

2. Date of birth

3. Specify your current address

4. Where you work or study?

5. Your contact phone number

Just enter digits of your number, additional characters will appear themselves

6. Your e-mail address

Access to the patient's personal account will be sent to the e-mail address you provide

7.

 Is the reason for the visit related to acute pain?

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.

 Do you have children?

10.

 How do you prefer to communicate with the center:

11.

 How have you felt emotionally over the past month:

12.

 How do you rate your physical activity during the week:

13.

 How much water do you consume during the day:

14.

 How would you rate the condition of your gastrointestinal tract:

15.

 How would you rate the quakity of your sleep (where 1 is not at all rested, 5 is fully rested):

16.

 How would you rate your level of inner energy:

17.

 How did you find out about us?

18.

 Are you currently taking any medications, what kind?

19.

 Do you have allergic reactions to:

20.

 Do you have any of the following conditions or diseases:

* 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

 
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