We know your time is worth a lot. For your convenience, you are welcome to complete the New Patient Form alongside, or, if you prefer, you can download and complete the patient intake form at home and email it to email@example.com.
Is the Person Responsible for account different from the Patient?
Do you or have you experienced any of the following?
Abnormal BleedingAnaemiaArtificial Bones/JointsArtificial ValvesAsthmaAnginaBreathing ProblemsCancerCold sore/Fever BlistersDiabetesDepressive IllnessEmphysemaEpilepsy/SeizuresFainting SpellsGlaucomaHeadachesHeart DisorderHay feverHaemophiliaHepatitisHerpesHigh Blood PressureHIV+/AIDSKidney ProblemsLung DiseaseLiver DiseaseLupusOsteoporosisPacemakerPain in Jaw JointsRheumatic FeverSeizuresSinus TroubleIntestinal DiseaseStrokeTobacco Use (Smoke)Tuberculosis (TB)TumoursUlcers
Please list any serious medical condition(s) that you have experienced:
Please list any medications you are currently taking:
Any Allergies that you are aware of?
Are you Pregnant?
Where did you hear about us?
I have read and accept the Mathee Dental Studio Payment Policy