Patient Registration Form Date * Full Name * Age * Sex * MaleFemaleOther Mobile Number * Profession * Select OPD Department * MedicalDentalPhysiotherapy Date of Birth Your Email Address * Complete Address * Medical History Checkbox List * DiabetesBlood PressureAsthmaThyroidCardiac DisordersEpilepsyPregnancyAllergiesBleeding DisordersRecent SurgeryOtherNone 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.
