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Dental Fiume New Client Form - English

QUESTIONNAIRE ON THE HEALTH STATE ACCORDING TO RECOMMENDATION OF FDI

Your Email

The patient should fill out the questionnaire personally by choosing YES or NO or answering the custom input question by providing a short answer.


Date of visit

First and Last name

Date of birth

Your Address

Your gender

Your gender

Your Profession

Your phone number

Name, address and phone number of emergency contact or closes relative

Please answer to all the following questions by yes, no or provide a short answer where required.

1. Do you suffer from any disease?

1. Do you suffer from any disease?
A
B

If you answered yes in the previous question, elaborate please?

Have you been in some kind of medical cure over the last two years?

Have you been in some kind of medical cure over the last two years?
A
B

If you answered yes in the previous question, which?

Name, surname and phone number of your doctor (in your home country).

Have you been hospitalized over the last two years?

Have you been hospitalized over the last two years?
A
B

Which drugs do you take, occasionally or permanently? If none, simply state "none".

Have you ever had any complications (or some of your relatives) during a complete or partial anaesthesia?

Have you ever had any complications (or some of your relatives) during a complete or partial anaesthesia?
A
B

Are you allergic to some medications?

Are you allergic to some medications?
A
B

If you said yes in the previous question, please write the details here.

Have they ever reported that you may suffer from blood clotting problems?

Have they ever reported that you may suffer from blood clotting problems?
A
B

Have you ever undergone radiation on your head and neck?

Have you ever undergone radiation on your head and neck?
A
B

Do you suffer from any infectious disease?

Do you suffer from any infectious disease?
A
B

Have you ever done blood transfusion?

Have you ever done blood transfusion?
A
B

If you answered yes to the last question, 

What kind of and when?

Have you ever come into contact with HIV virus?

Have you ever come into contact with HIV virus?
A
B

Are you HIV positive?

Are you HIV positive?
A
B
C

Question for women: are you pregnant?

Question for women: are you pregnant?
A
B

If you are pregnant, when is your due date?

Are you addicted to any drugs?

Are you addicted to any drugs?
A
B

If you answered yes to the previous question, please write which drug/s you are addicted to.

Please tick any or all of the diseases that you had/have. If nothing, select "None at all" at the bottom of the list.

Please tick any or all of the diseases that you had/have. If nothing, select "None at all" at the bottom of the list.

Your signature please.

Signature

APPROVAL STATEMENT FOR COLLECTION OF PERSONAL DATA

GDPR statement:
I hereby declare that, pursuant to Article 7. of the Personal Data Protection Act, I freely and explicitly accept to share my personal data (telephone number, e-mail ). These personal data will be processed in accordance with the Personal Data Protection Act. The Dental Fiume, Vladimir KIjajo dr.med.dent. will respect the privacy of the data, and no third party other than an employee or contractors of the dental studio will have access to that data. According to Article 7. of the Personal Data Act, this approval can be withdrawn at any time.
Signature

Do you allow us to use your data for occasional marketing purposes, such as promotional and exclusive offers sent by email marketing channels or sometimes by SMS/WhatsApp message or phone call?

Do you allow us to use your data for occasional marketing purposes, such as promotional and exclusive offers sent by email marketing channels or sometimes by SMS/WhatsApp message or phone call?
A
B

Based on article 241, step 2., of the Criminal Law (Official Gazette no. 110/97), I agree that Dr. Vladimir Kijajo, doctor of stomatology, undertakes all necessary stomatological and surgical interventions at his clinic located in Pore, Vrsarska Ulica 1a and issues the following declaration:

1. I accept stomatological treatments, surgical interventions (for my son/daughter*), as recommended by the stomatologist.

*For minors, the signature of their parents/guardians is required.

2 . I accept the anaesthesia, which the stomatologist believes is congruent with the agreed intervention.
3. I am aware of the fact that the success of the operation depends on the reaction of the body before, during and immediately after the operation, on the stomatologist and on the type of operation.
4. I am aware that the result and final effect of the intervention can be evaluated from six months to one year from the intervention performed.
5. I agree that photographs or x-rays are taken only for medical - health and professional purposes, respecting the privacy law.
6. I declare that I have received from the stomatologist all the requested and necessary information regarding the operation to which I decide to undergo.
7. I declare that, in the case of a failed operation due to negligence on the part of the Dr. Vladimir Kljajo, I will not make any legal complaint against him, because I am aware that in this case Dr. Kljajo undertakes to repeat the operation at his own expense.
8. I confirm that I understand everything, that I am fully aware and that I sign this declaration on my own spontaneous will.
Signature