Adult Registration Form

Smilefocus

Children Registration Form

Pre-treatment Information
Name*
Prefix First Name Surname
NRIC / FIN*
Date of Birth*
DD slash MM slash YYYY
Nationality*
Occupation
Street Address*
Address Line 2
Hidden
County / State / Region
Postal Code*
Home Phone
Mobile Phone*
Email Address*
When was your last visit to a dentist?
DD slash MM slash YYYY
Name & number of your medical doctor / clinic in Singapore
Prefer to receive your appointment reminder by*
- Telephone
- SMS
- Email
How did you hear about our clinics?*
- Magazine
- Google Search
- Event/ School Talk
- Social Media
- Word of mouth, Who
- Other
Who or Other*
Appointments
As a courtesy please do call us at least 24 hours before your appointment if you are unable to attend. Please call 3 days before your appointment for appointments of 90 minutes duration or longer. A missed appointment fee may apply. Thank you for your understanding.
Payments
- We accept all major credit cards, Nets, Cash and personal cheques.
- We offer a Direct Billing service to all our patients. Please ask at reception for more information.
- Payments are made to Dr Marcus Cooney & Associates Pte Ltd.
Medical History
The answers to the following questions will be helpful in the overall diagnosis of your case, and subsequent treatment will be planned to maintain not only dental health, but will contribute to your overall health state.
Have you had a recent illness?*
- Yes
- No
Do you have diabetes?*
- Yes
- No
Have you been exposed to Herpes / Cold sores?*
- Yes
- No
Have you had a reaction to local / general anaesthetic?*
- Yes
- No
Have you had excessive bleeding from extractions?*
- Yes
- No
Have you been exposed to HIV / AIDS?*
- Yes
- No
Are you or have you been a smoker?*
- Yes
- No
Are you Anaemic?*
- Yes
- No
Have you received any hospital treatment within the past year?*
- Yes
- No
Have you ever had:
- Heart trouble
- Heart murmur
- Heart valve prolapse
- Rheumatic fever
- TB
- Asthma
- Hayfever
- Bronchitis
- High blood pressure
- Hepatitis
- Epilepsy
- Allergies
List any medications you have been taking in the past year or are currently taking. Please include any natural or homeopathic medicines or supplements as sometimes these can cause harmful interactions with prescription drugs.
List any allergies
Females only:
Are you possibly pregnant?
- Yes
- No
specify estimated due date*
DD slash MM slash YYYY
Are you breast feeding?
- Yes
- No
We take our patients’ general health very seriously. Please remember that medical conditions or changes to medical conditions need to be brought to our attention so we can treat you effectively.
Dental History
These questions are designed to help identify any problems in your mouth and jaws. Together with a thorough clinical examination they will enable the dentist to provide an accurate diagnosis.
Do you currently have dental pain?*
- Yes
- No
Do you have a broken tooth or broken filling?*
- Yes
- No
Do you have sensitive teeth?*
- Yes
- No
Do any of your teeth feel loose?*
- Yes
- No
Do your gums bleed when you brush your teeth?*
- Yes
- No
Does food pack between your teeth?*
- Yes
- No
Have you ever had periodontal (gum/pyorrhea) treatment?*
- Yes
- No
Have you ever had orthodontic (braces) treatment?*
- Yes
- No
Do you grind your teeth during the night?*
- Yes
- No
Do you have any pain in or near your ears?*
- Yes
- No
Do you get neuralgia or migraine headaches?*
- Yes
- No
Do you have clicking jaw joints?*
- Yes
- No
Do you have stiff or sore facial muscles?*
- Yes
- No
Do you have a dental implant?*
- Yes
- No
Do you have a problem with snoring?*
- Yes
- No
Do you have any sores or lumps in your mouth?*
- Yes
- No
Have you had your 3rd molars (wisdom teeth) removed?*
- Yes
- No
Do you experience bad breath?*
- Yes
- No
Do you have an unsatisfactory denture?*
- Yes
- No
Do you have discolored teeth?*
- Yes
- No
Are you happy with the appearance of your teeth?*
- Yes
- No
Would you be interested in learning more about how your dentist can provide BTx-A to enhance your smile?
- Yes
- No
Had x-ray taken previously?*
- Yes
- No
Date of previous x-ray*
DD slash MM slash YYYY
Upload any relevant X-rays or medical reports if available
Drop files here or
Accepted file types: pdf, jpg, png, Max. file size: 25 MB.
What is the purpose of your visit?*
Signature
Signature
Date*
DD slash MM slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Working Hours.

Monday

08 AM - 10PM

Tuesday

08 AM - 10PM

Wednesday

08 AM - 10PM

Thursday

08 AM - 10PM

Friday

08 AM - 10PM

Saturday

08 AM - 10PM

Sunday

Closed

Our Location

Located in heart of Singapore

Call us
T: 6733 9882 or 6834 0877

Find us
Camden Medical Centre, #08-02/03 and #08-07, 1 Orchard Boulevard, Singapore, 248649

We are located on the 8th floor of Camden Medical Centre. We will send you a reminder a few days before of the appointment with the location and the dentist you will be seeing.

By car
There are two levels of basement parking in the Camden Medical Centre (accessible from Orchard Spring Lane). There is additional parking at the Regent Hotel, Hotel Jen and Tanglin Mall.

By bus
There is a bus stop adjacent to the Camden Medical Centre. Take bus numbers 75, 77, 105, 106, 111, 123, 132, 174e, 625, 634, 655, NR8. There is a free shuttle bus service every half hour to and from Orchard MRT station

Direct Billing

Dental Insurance

To ensure your visits to Smilefocus are as relaxed as possible we offer a direct billing service to your insurance provider. If your dental insurance cover does not pay for the account in its entirety, we charge your credit card, based on the information you have provided to us.