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Personal Info

Medical History

Dental History

Appointment

👤 Personal Information

Full Name *

Age *

Gender *

Phone Number *

Address (optional)

Emergency Contact (Name & Phone)

🏥 Medical History

Please answer Yes or No to each. This helps Dr. Shrawan prepare for your visit safely.

Are you currently being treated by a physician for any medical condition?

Do you have Heart Disease / High Blood Pressure?

Do you have Diabetes?

Do you have Asthma or any respiratory condition?

Do you have any known allergies?

Do you suffer from Gastric Ulcer or acidity issues?

Have you had any past surgeries (medical or dental)?

Are you currently taking any medications, supplements, or blood thinners?

Do you have any bleeding disorder (e.g. haemophilia)?

Do you smoke or use any form of tobacco (gutka, pan, etc.)?

Do you consume alcohol regularly?

Are you allergic to any antibiotics (e.g. Penicillin, Amoxicillin)?

Have you ever had a reaction to local anaesthesia (injection)?

🦷 Dental History & Current Complaints

Select all that currently apply to you:

📅 Appointment Preference

Service / Treatment Needed

Preferred Date

Preferred Time

Additional Notes / Questions

📲 How it works: Clicking "Send via WhatsApp" will compile all your information into a formatted message and open WhatsApp on your device, pre-addressed to the clinic (+91 7607504026). Simply press send!

Or reach us directly:

📞 +91 7607504026 💬 Direct WhatsApp 🏥 Apollo 24/7

📍 LG 4 & LG-5, 37/54, Capital Tower, Meston Road, Kotwali Chauraha, Kanpur UP 208001 | 🕔 5:00 PM – 9:00 PM (Mon–Sat)

👤 Personal Information

🏥 Medical History

🦷 Dental History & Current Complaints

📅 Appointment Preference

Or reach us directly:

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