Patient Registration – BDental Ortigas

Date *

Please select a date.

Patient's Full Name *

Please enter the patient's full name.

Facebook Messenger Name *

Please enter your Messenger name.

Patient Type *

New Patient Old Patient

Please select patient type.

Last Dental Visit / Cleaning *

Please fill in this field or write "N/A".

Purpose of Visit *

Please select at least one service.

Braces / Ortho Patients Only

Elastics Color *

⚡ Choose ONE COLOR ONLY. We do not allow elastics purchased or brought from outside.

Please select an elastic color.

Mobile Number *

Please enter a valid PH mobile number (e.g. 09XXXXXXXXX).

Email Address *

Please enter a valid email address.

Have you received the Covid-19 vaccine? *

No Yes Other

Please select an option.

Do you have any of the following? *

Senior Citizen ID PWD ID N/A

Please select an option.

Do you experience any of the following symptoms now? *

Please select at least one option.

I recognize that the clinic is adhering to the strictest infection control protocols for my protection and safety. I will abide by all health protocols implemented in the clinic.

I acknowledge and agree to the above statement. *

I AGREE

You must agree to the health protocol to proceed.

Submitted!

BDental Ortigas