Name of the patient
Nationality of the Patient
Sex  male female
Land line number
Mobile number
Give a brief Description about your Dental Problems. Also designate the teeth with number as above. Eg: Upper Right central incisor is 11
Lower Rights first molar 46
Any Medical Problems
(Ex. Diabetes, Hypertension, etc..)
Fillings done in teeth.
Root canal treatment done in any tooth.
Crown or Bridges on your teeth.
Missing teeth if any.