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Our Work
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INTERNATIONAL
PATIENTS
Home
About Us
AESTHETIC
Dermal Fillers
Neuromodulators
Threads
Facials & Peels
PRP
Mesotherapy
Aquagold Microneedling
Skin Care Products
DENTISTRY
SPECIALIST
Implants
Root Canal Treatment
Gum Treatments
Oral Surgery
Children Dentistry
Prosthodontics
Orthodontic Treatment
COSMETIC
Crowns & Bridges
Whitening
Porcelain Veneers
Composite Veneers
GENERAL
Inlays, Onlays, Fillings
Dental Hygiene
Headaches Relief
Bad Breath (Halitosis)
Our Work
Aesthetic
Dentistry
Contact Us
INTERNATIONAL PATIENTS
CALL NOW 0775646669
Home
About Us
AESTHETIC
Dermal Fillers
Neuromodulators
Threads
Facials & Peels
PRP
Mesotherapy
Aquagold Microneedling
Skin Care Products
DENTISTRY
SPECIALIST
Implants
Root Canal Treatment
Gum Treatments
Oral Surgery
Prosthodontics
Orthodontic Treatment
Children Dentistry
COSMETIC
Crowns & Bridges
Whitening
Porcelain Veneers
Composite Veneers
GENERAL
Inlays, Onlays, Fillings
Dental Hygiene
Headaches Relief
Bad Breath (Halitosis)
INTERNATIONAL PATIENTS
International Patients Jordan
Introduction
Navigating Your Journey
Tourism plan for international patients
Travel and Accommodation Assistance
Payment and Confirmation
Frequently Asked Questions (FAQs)
International Patients Turkey
OUR WORK
Aesthetic
Dentistry
Contact Us
International Patients
Navigating Your Journey
Patient Medical Chart
Patient Name
Date of Birth
Gender
Male
Female
Nationality
Phone
Email
Address
MEDICAL HISTORY
1. Are you currently under the care of a physician?
Yes
No
If yes, please provide details:
2. Do you have any known allergies?
Yes
No
If yes, please list:
3. Are you taking any medications or supplements?
Yes
No
If yes, please list:
4. Have you ever had a reaction to local anesthesia or dental materials?
Yes
No
If yes, please provide details:
5. Have you had any surgeries or hospitalizations in the past?
Yes
No
If yes, please provide details:
6. Have you ever been diagnosed with any of the following conditions?
Heart disease
Yes
No
High blood pressure
Yes
No
Diabetes
Yes
No
Bleeding disorder
Yes
No
Respiratory conditions
Yes
No
Contagious diseases like hepatitis B, C, and HIV
Yes
No
Other (please specify):
7. Are you pregnant or breastfeeding?
Yes
No
DENTAL HISTORY
1. Date of your last dental visit:
2. Reason for your visit to Dr. Abeer Ammouri Clinic:
3. Have you had any previous dental procedures?
Yes
No
If yes, please provide details:
4. Do you experience dental anxiety or phobia?
Yes
No
If yes, please provide details:
5. Do you smoke or use tobacco products?
Yes
No
If yes, please specify:
6. Are you satisfied with the appearance of your teeth and smile?
Yes
No
If no, please explain your concerns:
I confirm that the information provided in this medical chart is accurate and complete to the best of my knowledge. I understand that this information will be used to assist in planning and providing appropriate dental or aesthetic treatment at Dr. Abeer Ammouri Clinic.
Date
Send
4th circle, Ibn Khaldoun st.
Building #41
[email protected]
call now
+962 6 4646669
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