Request a Treatment Plan

STEP 01

Personal & Contact Details

Please provide your contact information so our clinical team can reach you.

Full Name *

Date of Birth *

Sex *

Nationality

Email Address *

Country of Residence *

Phone / WhatsApp Number *

STEP 02

Dental Concerns

Tell us about your main dental concern so our clinicians can begin a preliminary review.

STEP 03

Medical History

Please complete the medical history sections that apply to you.

Medications

Are you currently taking any medications?

Yes No

Please list all medications

Allergies

Do you have any allergies?

Yes No

If yes, please specify

Select all that apply.

Penicillin Other Antibiotics Local Anesthetics Latex Food Allergies Other

Details

Surgery, Hospitalization & Trauma History

Have you ever undergone major surgery, been hospitalized, or experienced significant trauma?

Yes No

Please provide details

Lifestyle Factors

Do you smoke?

No Former Smoker Current Smoker

If yes, number of cigarettes per day

Do you use any tobacco products?

Yes No

Do you consume alcohol regularly?

Yes No

STEP 04

Dental History

Share your previous dental care and the treatment you are considering.

STEP 05

Documents

Attach available records and photographs if you have them. None of these uploads are required to submit your request.

Medical Documents

Panoramic Radiograph (OPG)

Attach if available.

Optional. Max 8 file(s), 50 MB each. Accepted: pdf, jpg, jpeg, png, webp, tif, tiff, zip, dcm.

CBCT / Dental CT Scan

Attach if available. Large scans are accepted within the upload limit.

Optional. Max 8 file(s), 100 MB each. Accepted: pdf, jpg, jpeg, png, webp, tif, tiff, zip, dcm.

Periapical Radiographs

Attach if available.

Optional. Max 8 file(s), 50 MB each. Accepted: pdf, jpg, jpeg, png, webp, tif, tiff, zip, dcm.

Previous Dental Records

Attach if available.

Optional. Max 8 file(s), 50 MB each. Accepted: pdf, jpg, jpeg, png, webp, tif, tiff, zip, dcm.

Medical Reports

Attach if available.

Optional. Max 8 file(s), 50 MB each. Accepted: pdf, jpg, jpeg, png, webp, tif, tiff, zip, dcm.

Date of latest radiograph