• Confidential Medical and Dental History Form

  • The aim of this form is to assist your dentist in providing you with safe and optimal care.

  • Date of Birth
     - -

  • GP Details

  • Do you have or have you ever had any of the following?

  • Allergies to any of the following (please tick all that apply):

  • Medications

    Please provide details of any medications you take:-
  • Please list all the medicines or drugs (prescribed, over the counter or self medication) you take on a regular basis (including contraceptive pills, homeopathic and herbal remedies, ointments, recreational drugs). Please include dosages and frequency.
    Rows

  • Dental Information

  • Signature

  • I hereby apply to become a patient of Crendon Dental Centre. I undertake to settle all fees when due either at the time of treatment or in advance. If treatment is to be paid by a third party i.e. under insurance, I remain liable for those fees until the account is settled.

  • Date
     / /
    2 digit day, 2 digit month, 4 digit year
  •  
  • Should be Empty: