Sri ShankaraDental Clinic

Before your visit

Patient forms

Every new patient completes a registration form. It covers your contact details, your general health, the medicines you take and your dental history — all of which affect what treatment is safe and sensible for you.

Filling it in before you arrive saves about ten minutes in the waiting room, and gives you time to check your medicine names at home rather than trying to remember them at the desk.

Two ways to do it

1

Fill it in online

Complete the form in your browser and send it straight to the clinic. It saves as you go, so you can stop and come back to it.

Takes about 8 minutes. Works on a phone.

Start the online form

2

Download and print

Print it, fill it in by hand and bring it with you. Choose the language you are most comfortable reading.

No printer? Come ten minutes early and we will give you a copy at the desk.

What to bring with you

  • A list of your current medicines — including anything Ayurvedic, homoeopathic or herbal, and supplements. The strip or box is easier than trying to recall the name.
  • Any recent dental X-rays from another clinic, if you have them. It may save you having another taken.
  • Your insurance or scheme card if you intend to claim — Ayushman Bharat PM-JAY, CGHS, ECHS, ESIC, or a private policy.
  • Your ABHA number, if you have one. It is optional.

Bringing a child, or someone who needs help deciding

If the patient is under 18, or cannot give consent themselves, the parent or guardian completes the responsible-person section and signs the form.

How your information is handled

What you write on this form is confidential and is collected, used and stored in accordance with the Digital Personal Data Protection Act, 2023. You may ask to see it, ask us to correct it, or withdraw your consent at any time. Our privacy notice explains this in full, including who processes the form when you submit it online.

Anything you are unsure about, leave blank and ask at your appointment — or phone us on +91 89792 41142. If you are in pain or have had an injury, please phone rather than filling in a form.