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REGISTRATION

Multi-line address
Birth Date
Month
Day
Year

Medical History:

All information is strictly confidential as required by law. This information is vital to being able to provide you with the best treatment.


Please tick √ as applicable:

Have you had or do you have any of the following diseases? Select the one that applies:

List of medications, dietary supplements you are taking:

Who referred you to Gnathion Clinic?

Note: Doctor and patient should discuss any health issues prior to starting every dental treatment.

I certify that I have read and understood all the information presented in this form. I have also understood the importance of medical history and that my dentist and the staff of Gnathion Dental Clinic will receive the above information to provide me with correct treatment.

By signing this form, you are confirming that you are consenting to L.S. Gnathion Dental Clinic holding and processing your personal data for the following purposes. This information will be available exclusively to the Gnathion Dental Clinic Directory and shared only with the clinic staff. At any time after giving your consent, you will have the right to withdraw it by visiting the office, by contacting us electronically at contact@gnathionclinic.com or in writing, using the above contact details.

Registration Date
Month
Day
Year
Therapy Session

REGISTRATION

PERSONAL DATA

Medical History

At Gnathion Dental Clinic we are committed to protecting your privacy. As a result of a change in the EU law of data protection, your consent is now required, so we can continue to communicate with you according to your preferences.

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The Privacy Policy applies to information that constitutes personal data of individuals provided to L.S. Gnathion Dental Clinic, with the completion of a medical history and personal information upon your arrival at the doctor's office.

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We collect such information only directly from individuals and not through a third party. By signing this form, you give consent to L.S. Gnathion Dental Clinic to own and process your personal data for the following reasons.

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