Book Appointment — Dr Face Dental Clinic, Habsiguda

Patient Details

Full Name *

Phone *

Email

Date of Birth *

Gender

Address *

Appointment

Preferred Date

Specialization

Reason for visit

Medical History

Tick anything that applies. This helps us treat you safely.

Other medical conditions

Current Medication

Medications you are currently taking

Drug allergies

Patient Consent

Informed Consent

I voluntarily request and consent to the dental examination, diagnosis and treatment recommended by the dentists at Dr Face Dental Clinic, Habsiguda. I understand that:

The information I have provided about my medical history, medication and allergies is true to the best of my knowledge.
Dental procedures may carry risks including discomfort, swelling, infection or sensitivity, which will be explained to me before treatment.
I authorise the clinic to take dental X-rays, intra-oral photographs and digital scans necessary for my treatment.
My personal and medical information will be kept confidential and used only for treatment, communication and follow-up.
I may withdraw my consent at any time before treatment begins.

I have read and understood the above. I give my consent to proceed with the consultation and any treatment discussed.

Consultation Payment (₹300)

Choose one option to pay your ₹300 consultation fee. You can also pay at the clinic.

Pay via UPI QR

UPI QR code to pay ₹300 to Dr Face Dental Clinic

Scan to pay ₹300

UPI ID: drface@upi

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