top of page

Smile With Confidence

Home
Our Services
- General Dentistry
- Orthodontics
- Pedriatric Dentistry
- Cosmetic and Restorative Dentistry
- Teeth Whitening
- Facial Aesthetics
- Oral Surgery
- Dental Implants
- Periodontal (Gum) Treatment
- Dental Cleaning (Scaling and Polishing)
- Root Canal Treatment
- Joint Clicking, Pain and Grinding
- Sedation
- Oral Hygiene Program
- Retail
- Outreach Services
Q&A and Useful Information
- Types of Braces
- Types of Retainers
- Braces Tips and Care
- Adolescent Treatment / Phase II
- Teeth Shifting
Tsmile Floss
Contact Us
Email
Search
中文
More

Use tab to navigate through the menu items.

Personal Information

To register, please take the time to fill out the information below.

Title

Gender

Last Name

First Name

Birthday

Birth of Place

Age

Home Address

City

Home Telephone

District

Office Telephone

Email

Mobile

HKID No. / Passport No.

Occupation

Referred By (Please Specify)

Nationality

Name of Referral

Emergency Contact

Emergency Contact Person

Relationship

Emergency Contact Number

Medical History

Rheumatic or scarlet fever

Asthma

Chest (e.g. Bronchitis, TB)

Jaundice or Hepatits

Gastro-Intestinal

High Blood Pressure

Heart Pacemaker

Heart Problems

Diabetes

Epilepsy

Prolonged Bleeding

A.I.D.S./H.I.V

Major Surgery / Hospitalization

Allergic to

Drugs/Medication Prescribed

Other Medical History

I certify that the above information is complete and accurate. *

Signature*

Notes (For official use only)

Copyright © 2021 BRACES AND FACES ALL RIGHTS RESERVED.

bottom of page