THPDental - Declaration Form for Teeth Cleaning Without Dental Check-Up

Repulse Bay Office

Declaration Form

I hereby declare that I DO NOT wish to receive a dental examination by a dentist at THP Dental (Tam, Hulac & Partners Dental Ltd). I confirm that I have received a dental check-up from another dentist outside THP Dental within the last 12 months.

Details of the Dentist outside THP:

Dentist's Name

Date of Last Check-up

I refuse disclose the above information

Patient Name*

Phone Number*

Signature*