Smile Ready Bali · Dental Aesthetic

Patient Registration Form

Please complete this form accurately to help us provide you with the safest and most effective dental care. All information is kept strictly confidential.

01

Personal Information

02

Emergency Contact (in Bali)

Please specify someone who stays with you in Bali, in case of emergency.

03

Medical Background

Please tick if you have or have had any of the following:

04

How Did You Find Us?

05

Identification Document

To ensure the accuracy of your information and complete the registration process, please upload a photo of your KTP (local patients) or Passport (foreign patients). All personal information is kept strictly confidential and securely stored in compliance with data protection regulations.

06

Consent & Agreement

All information provided by you is accurate and will be held in the strictest confidence by Smile Ready. You acknowledge and agree that the clinic may document your treatment, including photographs and video recordings, for medical records, educational, and promotional purposes. Your identity will be handled in accordance with privacy regulations.

I confirm that the above information is accurate to the best of my knowledge. I agree to undergo dental examination and treatment as recommended. I consent to the clinic storing and handling my data for medical purposes in accordance with privacy regulations.

By submitting, you agree to our privacy policy.