Department Appointment

Dental Appointment Form

Schedule your visit with our dental specialists

Patient Name *

Patient name is required

Phone Number *

Valid phone number (7-15 digits) is required

Age *

Age (1-120) is required

Email *

Valid email address is required

Gender *

Gender selection is required

Nationality *

Nationality selection is required

National ID Number (e.g., A123456) *

Valid NID required (Format: A123456)

Address Information

Name/Building *

Example: Dhoonihuraa, Villa Name, etc.

Address name is required

Street *

Example: Fareedhee Magu, Road Name, etc.

Street is required

Island *

Example: Male', Addu, Fuvahmulah, etc.

Island is required

Atoll *

Select your atoll

Atoll selection is required

Student Information

Are you a student?

Yes

Discount Options (Optional)

Select Discount Type

Service Type

What type of appointment do you need? *

Consultation - General checkup or consultation with a doctor

Treatment - Specific dental treatment or procedure

Doctor *

Doctor selection is required

Appointment Date *

Valid date is required

Appointment Time *

Time slot selection is required

Reason for Visit *

Reason for visit is required

617:65617:65

Dental Appointment Form

Address Information

Insurance Information

Student Information

Discount Options (Optional)

Service Type

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