The aim of this form is to assist your dentist in providing you with safe and optimal care.
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.
If you take any more medications, please complete the details in the box below:-
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.