• 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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  • COVID-19 risk assessment

  • IF YOU HAVE RESPONDED POSITIVELY TO ANY OF THESE SYMPTOMS, WE WOULD STRONGLY ADVISE SELF ISOLATING AND DELAYING NON-ESSENTIAL CARE FOR AT LEAST ONE MONTH.

  • GP Details

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

  • Medications

    Please provide details of any medications you take:-
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  • 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.

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