Submitting registration…

✅

Submitted!

Your entry has been recorded. Please wait for clinic staff.

B. Dent Care Center HQ

Your Smile. Our Passion. Our Pride.

🦷 Patient Registration & Health Declaration

All fields marked * are required. The form cannot be submitted unless all required fields are filled.

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".

Service / Appointment

Purpose of Visit *

New Patient for Braces Braces Adjustment Tooth Restoration Tooth Extraction / Surgery Dislodge Bracket / Cut Wire Dentures / Fix Bridge Root Canal Treatment TMJ Treatment Implant Dentistry Consultation Oral Prophylaxis / Teeth Cleaning Teeth Whitening Molar Band Installation / Recementation Bite Plane Installation Retainer Installation / Adjustment / Repair X-Ray Only Dislodge Elastic / Loose Wires Wisdom Tooth / Impacted Tooth Removal Mouth Sore (Singaw) Gingivectomy / Gingivoplasty / Frenectomy Removal

Please select at least one service.

Elastics Color – Braces Patients Only

🔒 Select New Patient for Braces or Braces Adjustment above to unlock elastics color selection.

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

Gray

M. Blue

Green

Red

B. Blue

Teal

D. Blue

B. Pink

Pink

D. Violet

Blue

Purple

Barbie Pink

Black

Contact Details

Mobile Number *

Please enter a mobile number.

Email Address *

Please enter a valid email address.

Health Declaration

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? *

Colds Cough Fever Nausea Loss of Taste Sore Throat Allergic Rhinitis / Runny Nose Shortness of Breath Chills None of the above

Please select at least one option.

Acknowledgement

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.