Patient Registration

Join our personalized medical coaching program.

Quick registration

Create your account in one click with your preferred social network. You can complete the missing details afterwards.

Google Facebook

OR FILL OUT THE FORM

1. Personal information

Title

First name *

Last name *

Gender *

Date of birth *

Country of residence *

Wilaya *

Phone *

Secondary phone

Email *

Address *

2. General health

Do you have any chronic conditions?

Yes No

Are you taking any medication?

Yes No

Do you have any allergies?

Yes No

Are you pregnant?

Yes No

3. Dental status

Indicate what currently concerns you (for guidance only).

Dental pain Cavities Missing teeth Bleeding gums Heavy tartar Esthetic concerns (alignment, color…)

Other notes

4. Consent to participate in a training session

I understand that:

Treatments will be performed by trainee practitioners (dental surgeons), under the supervision of qualified professionals.
Treatments may take longer than in a regular clinic.
I may ask all my questions before and during the treatment.

Acts that may be performed (depending on your case):

Scaling Cavity treatment Simple extraction Dental prosthetics Basic esthetic care

5. Authorization and commitment

I voluntarily agree to participate in these training sessions. * I authorize the treatments needed within the educational context. * I authorize (optional) photos or videos for educational purposes (without identification).

I accept the Terms and conditions of use and the processing of my personal data in accordance with Law No. 18-07 of 10 June 2018 on the protection of personal data. *

Secure online payment

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Who would you like to contact?

Secretariat Coordination

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