WAY TO PERFECT SMILE

       
Galina, Russia
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Treatment dental travelers
 

So, you decide to come to Ukraine and become our patient. At primary consultation all details are important. Full questionnaire information allow Dental Travel Agency (Ukraine) personnel to calculate treatment and travel service options as precisely as possible.

Application for treatment by Dental Travel Program

Registration data

Full name

Date of birth

Country

City/town

Address

Mobile number

Å-mail

Accompanying person no yes

MEDICAL HISTORY

Further information is extremely important to provide you with effective dental treatment according to your general health. Please, give correct and complete answers to all questions. Incomplete or wrong information can damage your health. We guarantee confidentiality of your answers.

Your weight

Your height

Are you under the care of physician at present or during the past 2 years? no yes

If “Yes”, indicate the reason


Are you taking any drug continuously?
((at present or during the past 2 years)? no yes

If “yes”, specify the drug


Have you been a patient in the hospital during the past 2 years? no yes

If “Yes”, indicate the reason of treatment


Are you allergic (skin itching, rash, swelling, conjunctivitis etc.)?
Are you allergic to penicillin, aspirin, codeine or any drugs or medications?
no yes

If “Yes”, indicate the medicine and caused symptoms


Have you ever had any excessive bleeding requiring special treatment? no yes

When you climb stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath or because you are very tired? no yes

Do your ankles swell during the day? no yes

Do you take more than 2 pills to sleep? no yes

Do you ever wake up from sleep short of breath? no yes

Are you on a special diet? no yes

Do you suffer from oncological disease? no yes

BLOOD GROUP RHESUS

If you are currently treated (had been treated before) or know (suspect) the following diseases or states in your body, specify:

rheumatism
rheumatic heart disease
heart murmur (pain)
congenital heart disease
myocardial infarction
angina pectoris
arrhythmia
heart surgery
cardiac arrest
artificial heart valve
cardiac pacemaker
high (low) blood pressure
increased hemorrhage
anaemia
haemophilia (blood incoagulability)
blood transfusion
gastrointestinal disease
hepatitis À, Â, Ñ
jaundice
liver disease
asthma
tuberculosis
hay fever
hives
allergies to antibiotic, analgesic, local anaesthetic agents and other medications
drug addiction
benign [malignant] tumor
radiological treatment
radiation therapy
chemotherapy
diabetes mellitus
kidney trouble and urinary disease
difficulty of urination
dialysis
thyroid disease
paralysis
paresis
seizures
fainting
strokes
incoordination (hypotaxia)
neurosis
psychiatric treatment
epilepsy
loss of consciousness
arthritis
joint pain (arthralgia)
artificial joints
mandibular joint treatment
venereal diseases
herpes
genital herpes
AIDS
steroid therapy
ulcers
emphysema
head or neck trauma
car accidents

Do you have any other health problems which you know?
Add what you think is important:

DENTAL HISTORY

Figure out, what sum for the treatment will be appropriate for (please think about it and indicate,
it will save your and our time):

up to $2000
from 2 to $5 thousand
from 5 to $10 thousand
more than $10 thousand
any necessary sum for the treatment

Short description of the dental problem:


Supposed terms of the treatment:


Panoramic X-ray
Panoramic X-ray
Panoramic X-ray
Panoramic X-ray
Panoramic X-ray

Periapical X-ray
Sighting X-ray
Periapical X-ray
Periapical X-ray
Periapical X-ray

Intraoral camera images
Intraoral carema photo
Intraoral camera images
Intraoral camera images
Intraoral camera images

Digital camera images
Gigital camera photo
Digital camera images
Digital camera images
Digital camera images

Amateur camera images
Amateur camera photo
Amateur camera images
AAmateur camera images
Amateur camera images


Type of dental treatment Number Note
Implantation
Bone grafting
Metal-ceramic crowns
Ceramic crowns
Zirconium oxide ceramic crowns
Veneers
Braces
Whitening
Teeth restoration
Teeth root canal treatment
Dental prosthesis
Other (describe)


Request for clinic or doctor:


TOUR SERVICE


Visa
Transfer
Hotel
Appartment
    Maximal sum for accommodation per person
Escort
Interpreter
Excursion
Other






 
 

Copyright © 2009 Dental Travel Agency (Ukraine, Kyiv). Dental Trip. Dental Tourism. Dental Tour. Dental Tourist.

 
Cristiano van der Ham
Ñristianobrasil@live.nl +31626679132 The Netherlands

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