Sumastre Dental Care
Aesthetic Clinic
Fill out the patient form to register your information.
Patient Registration
Sumastre Dental Care
Aesthetic Clinic
Patient Information
Please fill in your personal details.
Emergency Contact
Medical History
Please answer the following questions about your health.
Do you have any of the following allergies?
1. Antibiotics
2. Dental materials
3. Latex
4. Local anesthetics
5. Metals
6. Pain medications
7. Sulfa drugs
Others, please specify:
Do you have any of the following conditions?
1. Autoimmune disease
2. Bleeding disorder
3. Cancer and ongoing treatments
4. Diabetes
5. HIV/AIDS
6. Heart disease
7. High blood pressure
8. Kidney disease
9. Neurological disorder
10. Pregnancy
11. Respiratory disease
12. Stroke
Others, please specify:
Do you have any of the following medications?
1. Antibiotics
2. Anti-anxiety medications
3. Antidepressants
4. Antihistamines
5. Blood thinners
6. Blood pressure medications
7. Hormonal medications
8. Immuno-suppressants
9. Diabetes medications
10. Pain medications
11. Steroids
Others, please specify:
Dental History
Tell us about your previous dental experience.
Profile Photo *
Please upload a recent photo of yourself. This will help us identify you when you visit the clinic.
Informed Consent *
Please read and accept all consent items below to proceed.
Digital Signature *
Please draw your signature below to complete your registration.
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