Committed to care

Damansara Jaya, Petaling Jaya

Welcome to iSmile

Please tell us a little about yourself before your visit.

Who is this form for? *

Myself My child, or someone I care for The questions still say "you" — please answer them about that person.

About you

Full name, as in your IC or passport *

Preferred name (optional)

Identity card (IC) number *

I do not have a Malaysian IC

Passport number *

Nationality *

Date of birth *

Gender *

Male Female

Occupation *

Please tell us *

How you found us

How did you hear about us? *

Who referred you? *

We would like to thank them.

Please tell us *

How to reach you

Mobile number *

The number that receives WhatsApp.

Email address (optional)

Home address

Address line 1 *

Address line 2 (optional)

Postcode *

Town or city *

State *

Emergency contact and payment

Someone we can reach quickly if there is ever a problem during treatment.

Their name *

Their relationship to you *

Their mobile number *

Parent or guardian

The patient is under 18, so we will contact you rather than them about their care.

Your name *

Your relationship to the patient *

Your mobile number *

Your email address *

Who is responsible for payment? *

Myself Someone else

Their name *

Their mobile number *

Their email address (optional)

Your dental and medical history

Please answer every question, even if the answer is no.

Your dental history

When did you last see a dentist? *

When were your teeth last professionally cleaned? *

Have you ever had bleeding that would not stop after a tooth was taken out? *

Yes No I've never had a tooth taken out

Your medical history

Have you been under the care of a doctor in the last 2 years? *

Yes No

What condition are you being treated for? *

Your doctor's name and clinic *

Your doctor's contact number (optional)

Are you taking any medicines? *

Including anything from a pharmacy, and any blood thinners or heart medicine.

Yes No

Please list them *

If you are not sure of the names, bring the boxes with you.

Are you allergic to anything? *

Medicines, latex, foods, metals.

Yes No

What are you allergic to, and what happens? *

Please say what happens as well.

Has a doctor told you to take antibiotics before dental treatment? *

Some heart conditions and joint replacements need antibiotic cover before we start.

Yes No I'm not sure

What were you told to take? *

For women

Pregnancy and breastfeeding change which X-rays we take and which medicines we can use.

Are you pregnant? *

Yes No Possibly

Are you breastfeeding? *

Yes No

Are you taking oral contraceptives? *

Some antibiotics can affect how well they work.

Yes No

Permission and signature

Declaration

Who is signing this form? *

I am the patient I am the parent or guardian, signing for the patient

Name of the person signing *

Your relationship to the patient *

Please sign below *

Sign here

Thank you. We have your details.

We will go through your medical history briefly with you when you arrive — it is just a quick check, nothing to prepare.

When you come in

Please arrive about ten minutes before your appointment time, and bring your IC or passport. If anything about your health or your medicines changes before then, just tell us at the desk.

Where we are

No. 75G & 75A, Jalan SS22/23, Damansara Jaya, 47400 Petaling Jaya, Selangor
Tel +6 03 7727 2135 · www.ismile.com.my

Committed to care

Welcome to iSmile

About you

How you found us

How to reach you

Home address

Emergency contact and payment

Parent or guardian

Who is responsible for payment? *

Your dental and medical history

Your dental history

Your medical history

For women

Thank you. We have your details.

When you come in

Where we are

Front desk — type straight down this list

iSmile Dental Clinic — Patient Registration

Welcome to iSmile

About you

How you found us

How to reach you

Home address

Emergency contact and payment

Parent or guardian

Who is responsible for payment? *

Your dental and medical history

Your dental history

Your medical history

For women

Permission and signature

1. Treatment and your dental care

2. Appointment reminders and check-up reminders

3. How long we keep your records

Declaration

Everything I have told you is true

Thank you. We have your details.

When you come in

Where we are

Front desk — type straight down this list

iSmile Dental Clinic — Patient Registration