Adult form Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of birthageGenderMaleFemaleOtherDo you floss?YesNoTooth Brush being usedSofthardRaceWhiteBlackIndian/AsianHow many times do you brush your teethWhat toothpaste do you use?What dental problem made you contact us today?Do you gums bleedYesNosometimesDo you experience sensitivityYesNosometimesDo you have any medical conditionsYesNoIf yes please specify Are you on medication?If yes Please provide name of medicationAre you undergoing any treatment at the hospital?YesNoIf yes what for and how longDo you smokeYesNoSometimesIf yes what do you smoke And for how longDo yo drink YesNoSometimesAre you pregnantYesNoIf yes how many months or weeksAny allergiesYesNoIf yes please specifywhen was your last teeth cleaning done 6 months ago12 months agomore than a year How or you when was your last dental appoint6 months ago12 months agomore than a yearPayment method CashMedical AidMedical Aid patients please indicate what medical aid are you on and what optionReligion?Submit
