Patient Registration Form

Please complete the form below before your appointment. It mirrors our in-clinic patient record so we can serve you faster and more safely on the day of your visit.

Patient Information

Patient’s Name

Age

Sex

Date of Birth

Civil Status

Address

Contact #

Occupation

Email (optional)

Preferred Dentist

Appointment Schedule

Choose a date, then pick from the times still available. Fully booked times are hidden. We are open Monday to Saturday, 9:00 AM to 6:00 PM.

Preferred Date

Preferred Time

Chief Complaint & Dental History

Chief Complaint

Dental History

Medical History

Check all that apply.

AsthmaHypertensionAllergiesCancerCardiovascular Disease (CVD)Previous OperationsCOVID-19 Vaccine

Other conditions / current medications

Personal / Social History

SmokerDrugsAlcohol

Others

ConsentI grant permission to the attending dentists of Golingan-Velez Dental Clinic, Dr. Merrybelle Christie G. Velez & Dr. Theressa Nicole G. Velez, to prescribe and perform the dental treatment discussed, including the use of anesthesia or sedatives if deemed necessary. I confirm the information above is accurate to the best of my knowledge.

Your information is kept private and used only for your dental care.

Golingan-Velez

Gentle, modern dentistry built on trust. Your smile, cared for like family.

Visit Us

Davao City, Philippines
+63 991 924 3051
Monday to Saturday, 9:00 AM to 6:00 PM

Quick Links

About the Clinic
Our Services
FAQ
Patient Record Form

Dr. Merrybelle Christie G. Velez & Dr. Theressa Nicole G. Velez