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  • Confidential Medical Questionnaire

    All your details will be kept strictly confidential

  • Title*
  • Date Of Birth:*
     / /
  • Gender*

  • We send SMS and email reminders, please provide us with appropriate contact details

  • Last dental visit?*
     - -

  • To provide the safest treatment Your Dentist needs to know of any medical issues which may affect your treatment

    Do you have or have you ever had:

  • Heart disease eg:  Angina, Heart attack, Heart murmurs, Valve problems, Heart surgery*
  • Pacemaker fitted*
  • Stroke*
  • High Blood Pressure*
  • Bleeding disorders (eg: anaemia, anticoagulant treatment)*
  • Rheumatic Fever or Endocarditits*
  • Thyroid / other hormonal disorder*
  • Bronchitis*
  • TB*
  • Asthma*
  • Any other chest disease*
  • Chemotherapy / Radiotherapy*
  • Bone or joint disease? (e.g. Arthritis, osteoporosis) Bisphosphonate medication*
  • Diabetes*
  • Eczema*
  • Dermatitis*
  • Epilepsy, Convulsions, Neurological disease*
  • Hepatitis*
  • HIV*
  • Liver or Kidney disease*
  • Learning difficulties*
  • Mental illness*
  • Bad reaction to anaesthetics*
  • Any other infectious disease*

  • Are you:

  • Currently under care of a Doctor or hospital for ANY treatment?*
  • Taking ANY medicines prescribed or over–the-counter? (Incl. Use of steroids over the past 2 years)*

  • Allergic to any of the following:

  • Penicillin*
  • Latex*
  • Chlorhexadine( ‘Corsodyl’)*
  • Do you have any other Allergies?*
  • Could you be pregnant?
  • Due date:
     / /
  • Are you a nursing mother?

  • How much of the following do you consume per day?

  • Next of kin: Please name a person we can contact in the event of an emergency during your visit with us

  • 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*

  • 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

  • Date:
     / /
  •  
  • Should be Empty: