Medical History

Confidential Medical Questionnaire

All your details will be kept strictly confidential
Title*

MissMrsMsMrNo title
Name*

First nameMiddle nameLast name
Date Of Birth:*

DayMonthYear
Gender*

FemaleMaleNon Binary
House/Flat No:*
Street:*
Area:*
City:*
Post Code:*
We send SMS and email reminders, please provide us with appropriate contact details
Telephone*
Email*
example@example.com
Name of your GP Surgery*
Your NHS number
Last dental visit?*

MonthDayYear
Date
Your occupation
How did you hear about our practice?*

Next of kin: Please name a person we can contact in the event of an emergency during your visit with us
Full name:
Phone:
Relationship to you:

You can find our full Data Protection Policy incl. Third party policy on display in the reception area and on our website

We contact all our patients by SMS and / or email with important notification such as:

Appointment reminders / Confirmation /Automatic recalls when it’s time for your next routine appointment / Updates of our Terms and Conditions / Changes to our opening hours or basic fees
Do you also want notifications about News, Product & Service information or promotions? eg Time Limited Teeth whitening offers General / Specialist treatment information*

Yes pleaseNo thanks
If you change your mind later, to opt in/out simply inform our reception team who will amend your preferences

*Important; if you forget to inform us of a new phone number/email you will not receive our appointment reminders*
Please note that we are required to update your Medical Questionnaire for each new course of treatment
Signature:*

Clear
If you are signing on behalf of the patient then please state your relationship:
Date:

DayMonthYear
Date
Should be Empty:

Are you: