Teledentistry

Geetanjali Dental Options

Fill This Form Properly,Advice will be given accordingly.













Mode of Contact

MEDICAL HISTORY : Select if you have any medical problem

listed below (Select "None of above" if not applicable):-

AsthmaBlood Pressure (High)Blood Pressure (Low)Kidney diseaseBleeding DisorderMigraineStomach ulcersDiabetesHepatitis/JaundiceThyroid (High)Thyroid (Low)Tuberculosis (TB) in last 5 yrsAcidityHIV/AIDSNone of AboveOthers

Specify Medicines & dosage if you are taking for any purpose


Any Allergy:-

Local AnesthesiaAspirinLatexPenicillinAny AntibioticIodineMetalAny otherNot Applicable

For Women Only

Current Pregnancy : NoCurrent Pregnancy : YesNursingTaking Birth Control PillsNot Applicable

Declaration:




Click

Submit

Button

Below

Call Now Button
×