Dental Clinic

Home
E-consultation
Medical Tourism
Services
Reservation
Blog
Contact
AR

E-Consultation

We consider providing the highest quality of services a great honour. We always strive to provide the best possible care in a comfortable atmosphere, to leave a good impression on our patients, and have them departing with everlasting & fond memories.

Please fill first form

Please fill in all the required fields below to fill second form

Medical Form

First Name

Last Name

Phone/Mobile

Dental Complaints

Bad breath ?

Yes

Bleeding gums?

Yes

Clicking / painful / popping jaw ?

Yes

Food collection between teeth ?

Yes

Grinding teeth ?

Yes

Loose tooth or broken fillings ?

Yes

Periodontal treatment ?

Yes

Sensitivity to hot/cold/sweets ?

Yes

Sensitivity when biting ?

Yes

Sores or growths in your mouth Appearance ?

Yes

Medical History

Arthritis, Rheumatism

Yes

Artificial Heart Valves

Yes

Artificial Joints

Yes

Asthma

Yes

Back Problems

Yes

Blood Disease

Yes

Cancer

Yes

Chemotherapy

Yes

Circulatory Problems

Yes

Cough, Persistent

Yes

Diabetes ( Type I / II )

Yes

Epilepsy

Yes

Fainting

Yes

Glaucoma

Yes

Headaches

Yes

Heart Problems

Yes

Hemophilia

Yes

Hepatitis ( A / B / C )

Yes

Scarlet Fever

Yes

Skin Rash

Yes

Stroke

Yes

Swelling of Feet or Ankles

Yes

Thyroid Problems

Yes

Tobacco Habit ( smoking / chewing )

Yes

Tuberculosis

Yes

Ulcer

Yes

Venereal Disease

Yes

High Blood Pressure

Yes

HIV/AIDS

Yes

Jaw Pain

Yes

Kidney Disease

Yes

Liver Disease

Yes

Mitral Valve Prolapse

Yes

Pacemaker

Yes

Pregnant

Yes

Radiation Treatment

Yes

Respiratory Disease

Yes

Rheumatic Fever

Yes

ALLERGIES:

Aspirin

Yes

Codeine

Yes

Local Anesthetic

Yes

Penicillin

Yes

Sulfa

Yes

Latex

Yes

Other

Yes

LIST MEDICATIONS: List medications you are currently taking:

DISCLAIMER:

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Date / Time

Signature

Phone

(+20) 115 2214 743

Email

info@dr-maan-shamma.com

Address

Al Obour, Al Qalyubia Governorate , khaled ben waleed street