Medical record

Below you will find a series of questions related to your health. It is extremely important that you answer them honestly, as they could be crucial in planning and carrying out your treatment.

This information will help us take all the necessary precautions and safeguards for your health, as well as contribute to providing you with appropriate dental care. If you are unsure about any of the questions, or do not understand its meaning or importance, or how it relates to your health, please discuss it with the dentist.

Personal data

Birthdate:

(Write the guardian's information if the patient is a minor)

example@example.com

Please indicate the name of the company, whether you are self-employed, a homemaker, or unemployed.

Personal Medical History

(It is the patient's responsibility and duty to indicate any medical condition that comes to their knowledge)

Headaches, seizures, dizziness, paralysis - Anemia, blood disorders or clotting problems - Ulcer, gastritis, cirrhosis, colitis, hemorrhoids - Asthma, tonsillitis, emphysema, laryngeal or bronchial conditions - Thyroid diseases, alterations in blood lipids or uric acid - Surgeries, traumas (accidents) - Cancer, tumors, radiotherapy or chemotherapy - Kidney diseases.

Diabetes

Infectious diseases: Have you had or suspect you have Hepatitis, tuberculosis, AIDS or HIV (+), syphilis or any other serious infectious disease?

Hypertension, heart attacks, angina, heart murmurs, arrhythmias, coronary artery disease, heart valve

Dental History

(Please only check the option that applies)

Have you undergone any previous dental treatments?

Do you use or have you used any type of appliance (braces, habit breaker, space maintainer, other oral appliance)?

Have you had any extractions or oral surgery?

If yes to the previous answer, have you experienced any complications? Paresthesia, poor wound healing, or heavy bleeding?

Do you suffer from cheilophagia (lip biting) or onychophagia (nail biting)?

Do you suffer from bruxism? (Teeth grinding)

Does he/she suck his/her thumb, or did he/she suck his/her thumb as a child?

Have you had a negative experience during a previous visit to the dentist? Or do you have a phobia?

Do you use dental floss, mouthwash, or other oral hygiene products?

Dental History

(Please only check the option that applies)

Declaration: The patient acknowledges and declares that all information indicated or omitted in this clinical record is their sole responsibility, expressly releasing DENTAL GLOBAL from any liability, both civil and criminal, that may arise as a result of erroneous, incomplete, false or omitted information.

The patient provides this information only for the purposes of their procedure; this information may not be disclosed to third parties without their prior consent except as required by law.

The patient who signs this form expressly declares that they know and accept to their full and total satisfaction the above.

Declaration of Acceptance of Rates and Policies:

I acknowledge that the initial consultation costs RD$3,700.00 without insurance and RD$1,700.00 with accepted ARS (Health Risk Administrators). This amount covers prophylaxis, provided there are no special conditions such as bleeding gums, braces, or veneers. I voluntarily accept this fee, regardless of my insurance coverage, as it is the clinic's INITIAL consultation policy. I understand that the prices for other services will be provided in a treatment plan with applicable coverage, and by agreeing to any treatment, I acknowledge the price set by the clinic, waiving any subsequent claims against either the clinic or the insurance company. I understand that a panoramic X-ray, costing RD$800.00, allows the doctors a more complete evaluation of my mouth and is necessary to justify treatments to the insurance company.

I declare that I was informed that, in case of paying for any procedure in advance and deciding not to have it done, the center, according to internal policies, will retain 30% of the amount paid.