Registration Form



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    I hereby authorize and direct that dentist(s) assisted by other dentists of his choice, to perform upon myself or my child (or legal ward for whom I am empowered to consent) the checked dental treatment(s). I certify that I have read and understand this consent form, that I have been given an opportunity to ask questions, and that all questions about the procedure(s) having answered in a satisfactory manner. No guarantee has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. I understand further that I have the right to be provided with answers to question that may arise during the course of my treatment or that of my child. I further understand that I am free to withdraw my consent to treatment at any time, and that this consent will remain in effect until such time that I choose to terminate it.
    I have been advised that medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and co ordination, thus I have been advised not to operate any vehicle or hazardous device for atleast 24 hours or until fully recovererd from the effect of the anesthetics, medications and drugs that may have been given me for my care. I agree not to drive myself home and to have a responsible adult accompany me until I Am recovered from my medications.




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    Smile Kochi Dental Clinic, Palarivattom

    Pipeline Rd, Sonia Nagar,
    Palarivattom.
    Ph: 0484 4861100.
    Ph: +91 9447359099.

    Smile Kochi Dental Clinic, Kadavanthra

    Opposite Kendriya Vidhyalaya,
    Gandhi Nagar, Kadavanthra.
    Ph: 0484 3518000.
    Ph: +91 8877077079.

    Opening Hours

    Mon - Fri: 9:30 AM - 6:30 PM

    Appointment Booking

    Appointment Booking

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