PATIENT FORM

Dear Patient, Please take a few minutes to complete this questionnaire before your session. The information you provide will help the doctor to be better prepared and make the session as helpful as possible for you.

- Step 1 of 3

PATIENT NAME *

First

Last

DATE OF BIRTH *

WORK

ADDRESS *

Address Line 1

City

State / Province / Region

Postal Code

Country

PHONE (HOME)

MOBILE PHONE *

E-mail

1) Do you currently have or have you had in the past any of the following?

AIDS/HIV
Diabetes
Stroke
Pregnancy
Epilepsy
Hepatitis A, B, C
Heart problems
Kidney, adrenal gland, or liver diseases
Respiratory disorders
Thyroid disorders
Tuberculosis
Other
None of the above

1) Do you currently have or have you had in the past any of the following? *

2) Are you currently taking any medications regularly? If yes, which ones? *

No
Yes, which

2) Are you currently taking any medications regularly? If yes, which ones? *

3) Do you have any allergies to medications, food, or other substances? *

No
Yes, please specify:

3) Do you have any allergies to medications, food, or other substances? *

4) Is there anything else you would like the doctor to know?

How did you find our clinic?

Recommendations
Google search
Facebook / Instagram

I agree to the processing of my personal data for the purpose of conducting the session *

I have read and accept the Terms of Use and the Privacy Policy.

Η ΤΟΠΟΘΕΣΙΑ ΜΑΣ

DENTAL CLINIC
“KONSTANTINIDIS DENTAL”

MICHALAKOPOYLOY 84 & LAODIKIAS 9-11, 1st floor, 11528 athens

(METRO STATION MEGARO MOYZIKIS)

info@konstantinidisdental.gr

Τ/Φ: +30 216-070-2280

Τ: +30 693-8585-170 (Viber, WhatsApp)

Book your appointment!

Open hours

Monday — Saturday

09:00 — 18:00

GIFT CARD

GDPR

Career