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Country You Reside In? (Your Home)
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Date of Birth (Please provide CORRECT YEAR of birth)
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Emergency Contact Person & Phone Number (travel companion,family,caregiver,close friend)
Approximate Date of Arrival in Thailand
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Date Format: DD slash MM slash YYYY
Estimated Length of Stay in Thailand? (Days)
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This will determine the possibility & options of your inquired dental treatment.
Treatment(s) you are seeking?
*
Dental Implant(s)
Dental Crown(s)
Dental Veneer(s)
Root Canal Treatment
Filling
Tooth Extraction
Wisdom Teeth Removal
X-ray
Dental Root Formation
Gap Closing
Tooth Bridge
Cleaning + Fluoride Application
Teeth Whitening Zoom
Teeth Whitening Cool Light
Other
Please Select ALL that apply.
What dental treatment(s) are you seeking or have you been told are needed by your home country dentist?
*
Please describe in good details.
Dental History – What significant procedures have you already had done in the past?
*
Dental Implant(s)
Dental Crown(s)
Dental Veneer(s)
Root Canal Treatment
Filling
Tooth Extraction
Wisdom Teeth Removal
X-ray
Dental Root Formation
Gap Closing
Tooth Bridge
Cleaning + Fluoride Application
Teeth Whitening Zoom
Teeth Whitening Cool Light
Other
NONE
Select ALL that apply. This will help our dentists determine best dental solutions for you based on your current dental condition.
What dental treatment or devices do you currently have?
*
Dental Implant(s)
Dental Crown(s)
Dental Veneer(s)
Tooth Bridge
Braces
Filling
Dental Root Formation
Gap Closing
Other
NONE
Select ALL that apply. This will help our dentists determine best dental solutions for you based on your current dental condition.
Kindly describe the other existing dental devices or procedures you currently have
Do you currently experience any of the following:
*
Swelling in your mouth
Pain
Bleeding
Sensitivity
NONE
Please Check all that apply.
If yes to the question above, please specify when you experience it and which part of your mouth.
Please provide your personal health condition information. Kindly check all that apply:
*
Arthritis
Anemia
Asthma
Back Problem
Blood Clots
Blood Disorders
Bleeding Problems
Breathing Problems
Cancer
chest Pains
Colitis
Depression
Diabetes
Epilepsy
Heart Problems
Heart Murmur
Hepatitis
HIV or AIDS
Irregular Heartbeat
Kidney Problems
Liver Problems
Migraine/Headaches
Nervous Breakdown
Nose/Throat Problems
Osteoporosis
Pneumonia
Rheumatic Fever
Seizures
Skin Cancer
Stroke
Thyroid Problems
Tuberculosis
Transfusion
NONE of the above
Check all that apply.
For Women Only: Are you pregnant as of the moment?
Yes
No
Most pregnancies can disrupt surgery and traveling can disrupt pregnancies. Please discuss with your personal physician regarding this matter.
If Yes, please let us know how many months pregnant you are now
Have you had any dental/oral surgeries in the past? If so, please describe what was and when.
*
Yes
No
If Yes, please describe Any Previous dental surgeries
Are you allergic to any medications?
*
Yes
No
If Yes, please list the medication name and elaborate your reaction(s)
Have you had problems with Anesthesia?
*
Yes
No
If Yes, please provide details
Do you have artificial implants or any metal objects in your body? If yes, please specify.
*
Yes
No
If Yes, please provide details
Please list ALL Medications and/or supplements you are currently taking and the Daily Dosage (mg). Type "None" if there isn't any.
Medicine 1
Medicine 2
Medicine 3
Medicine 4
Please provide your dentist's name, his office name, contact number, and e-mail address.
What is your expectation from your Dental Treatment(s) in Thailand? And what is your most concerned dental problem you'd like solved in this trip?
How Did You Hear About the Dental Center of Thailand?
Google Search
Bing or Yahoo Search
Friend or Personal Referral
Magazines or News paper
TV Story or Other
Other – More Information on how your found us or Comments
If You Need To Send More Than 4 Oral X-rays or Oral Pictures, Please Email Them To:
Please Attach Any Pictures and/or Dental X-Rays files for Accurate Evaluation.
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
Please Attach Any Pictures and/or Dental X-Rays files for Accurate Evaluation
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
Please Attach Any Pictures and/or Dental X-Rays files for Accurate Evaluation
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
Please Attach Any Pictures and/or Dental X-Rays files for Accurate Evaluation
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
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Skype: Thai.Dental
Skype: Thai.Dental