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Carlos Alonso

Designer | Inside

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Alicia Martin

Content creator

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Say what you think,
do what you feel

Love

it is never a crime

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The Woman in Red

Cologne, Germany | ThemePunch

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No one is born hating another person because of the color of their skin or their origin, their sexuality or their religion. If they can learn to hate, they can be taught to love, because love is more natural to the human heart than its opposite. Nelson Mandelas

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Contact information

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Clinic history

Name

Birthdate

Age

Sex

Height

Weight

Home address

Telephone | Cell phone

Main Reason for Consultation

Identification document

Acceptance
I have read the medical history and I am going to respond with complete clarity without omitting any illness that I suffer from.

Reason why I visit the dental office

Has presented complications.
Yeah No

If you have suffered, indicate which

Are you currently being treated by a doctor?
Yeah No

If this is your case, indicate for what disease?

Are you taking any type of medication?
Yeah No

If this is your case, indicate which ones and with what dose?

Are you allergic to a medication?
Yeah No

If this is your case, indicate which ones and with what dose?

Expectations of your treatment in the case of being aesthetic:
Whiter tooth color Bigger teeth Smaller teeth

In the following list of diseases, please mark YES or NO, you have suffered from any. If your answer is affirmative, please describe the treatment received.

Epilepsy or Seizures
Yeah No

Treatment

Anemia
Yeah No

Treatment

Diabetes
Yeah No

Treatment

Hepatitis
Yeah No

Treatment

Hyper or Hypothyroidism
Yeah No

Treatment

Arterial hypertension
Yeah No

Treatment

Angina pectoris
Yeah No

Treatment

myocardial infarction
Yeah No

Treatment

Asthma
Yeah No

Treatment

Tuberculosis
Yeah No

Treatment

Renal insufficiency
Yeah No

Treatment

Venereal diseases
Yeah No

Treatment

HIV/AIDS
Yeah No

Treatment

Gastritis
Yeah No

Treatment

Pregnancy
Yeah No

Treatment

Menopause
Yeah No

Treatment

Cancer
Yeah No

Treatment

Others
Yeah No

Treatment

Extra oral clinical examination

Head

Expensive

ATM

Ganglia

Lips

Particular signs

Observations

Descargar Historía clinica

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Jeimy Pinto

Valencia Edo. Carabobo

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Thand QeitherwandrFandM

"Thand QeitherwandrFandm yeseithermeitheryes teitherdtoyes"

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ORnYoqorand grandandn gleitherbtol

SEE

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J.EITHERYesAND YesTTOORdANDR

MTONTOgANDR

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YesEITHERFYoTO YesTTOORdANDR

MTONTOgANDR

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H.O.
THE

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H.O.
THE

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Contact

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A digital card is the electronic version of the traditional business card.

Unlike the paper card, the digital card is shared quickly and easily through different digital platforms such as email, WhatsApp, LinkedIn, among others.

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