• Confidential Medical and Dental History Form

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

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  • Are you:-

  • Have you:-

  • Do you:-

  • If your appointment is not routine:

    Please give History and Information on your presenting complaint:-

  • Additional guidance regarding your attendance:

    Before arriving at the practice, we ask you to:

    • Thoroughly brush your teeth before leaving the house.
    • Use toilet facilities before leaving home and try to avoid using these in the practice.
    • Wash your hands for 20 seconds before leaving home.
    • Please wear a mask or face covering.
    • Ensure that you arrive outside the practice at least a few minutes before your appointment.
    • Appointment times have been staggered to avoid social contact in the building, therefore, punctuality is imperative.
    • Only enter reception at the exact time of your appointment. The front door may be locked, a nurse will call you in at the time of your appointment.
    • Unless absolutely necessary, attend your appointment on your own.
    • Bring as little with you as possible. Bags, hats and coats present a greater risk for cross-infection.
    • On the day prior to your appointment; complete a new medical history form, Risk Assessment form, COVID screening form and if needed a description detailing the nature of your complaint. These forms should be completed online.

     

  • Clear
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  • Should be Empty: