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Premium Dental Care in Bhubaneswar-The Pulp Dental Clinic
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Patient Name
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Gender
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Occupation
Date Of Birth
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Email
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Family Status
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Child
Mobile Number
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Alternative Mobile Number
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Address
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Last Dental Visit & Where
Other Source Referring You To Our Practice
Have You Had Any Serious Trouble Associated With Any Previous Dental Treatment
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Habit History
Are You a Tobacco User / Alcohol / Smoking
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Medical History
If You Are Taking Any Medications, List Here:
Name & Contact Number Of Your Physician
Do You Suffer From? (Please Put Tick)
ALLERGY TO DRUGS OR LOCAL ANESTHESIA
STOMACH ULCER OR HYPERACIDITY
ARTHRITIS OR PAIN IN JAW JOINTS
PARKINSONS DISEASE
ORGAN TRANSPLANT
ALZHEIMER'S DISEASE
CANCER
THYROID PROBLEM
BLEEDING DISORDER
KIDNEY DISEASE
HYPERTENSION
DIABETES
STROKE
TB
CARDIAC DISEASE
OSTEOPOROSIS
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SKIN ALLERGY
AIDS & HIV
ASTHAMA
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Are You Nursing?
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Declaration
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I, hereby declare that the above mentioned statements are true to the best of my knowledge and belief. And I authorize THE PULP RCTS & IMPLANTS to use it for the clinical purpose.
I, the undersigned, voluntarily consent to participate in an online consultation with The Pulp Dental Care. I understand that the consultation is not a substitute for an in-person evaluation. I consent to the collection and secure storage of my personal and medical information for the purpose of this consultation. I acknowledge that I have read, understood, and agree to the terms and conditions of this online consultation. *
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Visual Test
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Palpation
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Percussion
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