Registration for Check-up Camp Date Name Age Date of Birth Sex MaleFemaleOther Mobile Your email Profession Organization Address Select OPD MedicalDentalPhysiotherapy Medical History DiabetesBlood PressureAsthmaThyroidCardiac DisordersEpilepsyPregnancyAllergiesBleeding DisordersRecent SurgeryOtherNone Consent I undersigned, hereby in my full consciousness give the consent for- 1) Performing the clinical procedure that had been explained to me by Dentist/Doctor, I have clearly understood it and had no doubts about the same. 2) use of general/ local anesthesia/ sedation required for the clinical procedure. 3) the cost of clinical procedure and the payment terms of full advance, non-refundable and non-transferable as per the policy of iSmile Charitable Dental Clinic. 4) use of media such as x-rays, photos, videos to be used by iSmile charitable dental clinic for education, promotion or any other social concern.
