Title: * —Please choose an option—MissMrMrsMasterMs
First Name: *
Last Name: *
Occupation / School:
Date Of Birth: *
Mobile phone: *
Home phone:
Work phone:
Email: *
Address: *
Name: *
Phone number: *
Friend (please advise their name below)Word of mouthGoogleFacebookInstagramOther: (please advise below)
Referrer name: (If applicable)
Please let us know how you found us: (If applicable)
Medical doctor's name (GP):
GP's phone: (If known)
Do you require antibiotics before you receive any dental treatment? YesNo
Are you attending or receiving treatment from a doctor or hospital? YesNo
If yes, please provide further details:
Are you pregnant? YesNo
If yes, please advise details e.g. how many months:
Are you taking and tablets, medicines, pills, or drugs? (this includes any health supplements, regular medication from doctors, and recreational drugs) YesNo
If yes, please list:
Do you smoke? YesNo
If yes, please advise details:
Please tick the following conditions if any are applicable to you: Heart problems / pacemakers / angina / stroke / heart murmur / open heart surgeryRheumatic feverJaundice / liver diseaseAsthmaHigh blood pressureKidney problemsAnaemiaGastric problemsBronchitis or chest problemsDrug dependenceSinus / Hay feverSevere headachesHepatitis- specify type A, B, CDepressionEpilepsy / fainting attacks / blackoutsCold soresDiabetesArthritisRadiotherapyAllergiesExcessive bleeding / bruisingProsthetic surgery (heart valve, hip, knee replacement etc.)CancerOsteoporosisTaking or have taken FosamaxHIV/AIDSOther (Please specify)
Hepatitis type: (If applicable)
Other conditions: (If applicable)
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment our practice requires both the patient and staff member to undertake confidential blood tests. Do you agree to do a blood test if required? YesNoWish to discuss with the dentist
Please be advised by signing this document you agree that any accounts remaining unpaid without being discussed and approved by the dentist may be sent to debt collection where further action will be taken to collect the amount owed which may include but is not limited to further costs being added.
Full name: *
Signature: *
Date: *
