Please complete all questions
Name
*
Address
*
Phone Number
*
Date of Birth
*
Email Address
*
PPS Number
*
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Medical History
Have you any of the following conditions...
Arthritis
Pacemaker
Heart Surgery
Hayfever
Eczema
Chest Issues
Epilepsy
Fainting
Diabetes
Bleeds easy
Pregnant
Rheumatic Fever
Liver Disease
Hepatitis
Kidney Disease
Smoke
Heart murmur
Heart Problems
Heart Attack
Stroke
Joint Replacement
None of above
Other
Details about above conditions
Have you an allergy to Penicillin or any other allergies we need to be aware of?
*
Allergy to Penicillin
No Allergies
Other
Every in Hospital for anything serious that we need to be aware of?
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Are you currently attending your GP?
Do you take any medication?
Yes
No
If yes, names of any medication?
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Consent
I consent to my personal data being stored, Including PPS Number.
*
Yes
No
I consent to my information being shared with the following Parties only. Social Welfare for approval and payment and your GP or Pharmacy only when necessary.
*
Yes
No
I consent to receive appointment reminders and Confirmation via Text and or Email.
*
Yes
No
I consent to receive offers and promotion from Castle Street Dental via Text and or Email.
*
Yes
No
As part of your Dental assessment or treatment we may need to take X-rays. The amount of radiation from a dental X-ray is about the same as one of two days of natural radiation that we are all exposed to as part of our daily life. Do you consent to X-rays being taken?
*
Yes
No
Signature
*
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