TDH Pre-Assessment Dental Form

General information

Name

Medical history

Chronic disease (if any)
Current medications (if any)
Drug allergies (if any)
Food allergies
Surgical operation History (if any)
Organ Transplant (if any)
Do you drink alcohol?
Are you a smoker?
Do you currently have any existing dental fixtures, appliance?

Travel history

Do you reside in Thailand?
Do you have plans to travel abroad or travel by plane during this time?
Click or drag a file to this area to upload.
It will be helpful to get x-rays and/or any documentation of the previous dental work/s.

*This information will help our dental team prepare as best as possible for your safety.