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Patient Intake
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Dental Coordination & Concierge · International

Let's get you started.

Complete this intake form so we can understand your dental needs and build a personalized plan — at a fraction of US prices. Takes about 10 minutes.

Please complete all required fields before submitting.
1
Personal Information
We'll use this for all coordination
WhatsApp preferred for in-country support
How did you hear about us?
2
Dental Treatment Needs
What treatments are you interested in? Select all that apply *
What's bothering you most? What has your dentist recommended?
Have you received a treatment plan or quote from a US dentist?
3
Insurance & Budget
Current dental insurance status *
Approximate budget for dental treatment abroad (USD) *
How do you plan to pay?
4
Travel Availability & Preferences
When are you hoping to travel? *
How many days can you travel?
Traveling with:
Accommodation preference:
5
Health & Medical History
This information helps ensure the clinic is fully prepared for your care. All information is kept strictly confidential and only shared with the treating dental clinic.
Do any of the following apply to you? Select all that apply
Especially important: blood thinners, bisphosphonates, diabetes medications
6
Previous Dental Work
Have you had any of the following previously? Select all that apply
7
Your Goals & Preferences
What matters most to you? Select your top priorities
Preferred level of coordinator involvement
Nervousness about traveling, specific cosmetic goals, timeline pressures, budget concerns — all welcome
8
Consent & Authorization

Please read and check each item below to complete your submission.

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We'll respond within 24–48 business hours with personalized next steps.

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Thank You!

Your intake form has been received. A member of our coordination team will review your information and reach out within 24–48 business hours to discuss next steps.

Ready to move faster? Book your free discovery call now →

Questions in the meantime? Email us at hello@signaturesmile.co