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Kekala Dental Concierge Services

Dental Intake Questionnaire

Our intake process bridges remote clinical evaluation with in-person execution. Please complete this form carefully. The information provided enables our partner clinical team to design your customized treatment plan while ensuring all travel, logistical, and safety standards are met.

Section 1

Patient Details & Travel Info

Valid passport (6+ months validity remaining)?
Do you require a travel visa for the Philippines?

Section 2

Dental History & Chief Complaint

Have you experienced issues with local anesthetics, heavy bleeding post-extraction, or slow healing?

Do you grind your teeth, wear a nightguard, or suffer from jaw joint (TMJ) pain or clicking?

Section 3

Diagnostic Assets Availability

Please upload digital files (.DICOM, JPEG, PNG) alongside this form.

Have you received a treatment plan or quote from a local dentist recently?

Please provide clear smartphone photos of:

  1. Front teeth biting normally
  2. Upper arch
  3. Lower arch
  4. Full smile

Section 4

Dental History & Surgical Risk Assessment

Tobacco / Nicotine / Vape use?
Regular alcohol consumption?
Currently pregnant or nursing?

Section 5

Logistics & Accommodations Preference

Do you require wheelchair assistance or ground-floor accommodation?

After submitting, please email any imaging files or treatment plans to Patient-Intake@kekaladental.com