New Patient Online Form

 
 
Name *
Name
Date of Birth
Date of Birth
Address
Address
Home Number
Home Number
Work Number
Work Number
Mobile Number
Mobile Number
Preferred Contact Number
To help us assess your dental needs, please tick any of the issues below which concern you.
Doctor's Address
Doctor's Address
Strictly Confidential
We ask you for information about your general health to help us treat you safely. Please complete the form and sign it where indicated. All information will be kept confidential by the people caring for you.
Are you Currently:
Are you currently attending or receiving treatment from a doctor, hospital or specialist?
Are you currently taking any medicines from your doctor? (Tablets, Ointments, injections or inhalers, including Contraceptives and hormone replacement therapy?)
Are you currently allergic to any medicines or substances?
Are you currently pregnant?
Have you:
Have you had rheumatic fever?
Have you ever been told you had a heart problem or heart attack, angina or blood pressure issues?
Have you had any blood tests or inoculations?
Have you had your blood refused by the blood transfusion service?
Have you had a bad reaction to local or general anaesthetic?
Have you had a joint replaced?
Have you been hospitalised?
Smoking and Drinking:
Do you smoke any tobacco products now or in the past?
Do you:
Do you have arthritis?
Do you have a pacemaker, or had any form of heart surgery?
Do you suffer from hayfever, eczema or other allergy?
Do you suffer from bronchitis, asthma or other chest condition?
Do you have fainting attacks, giddiness, blackouts or epilepsy?
Do you have diabetes or does anyone in your family?
Do you bruise easily following a tooth extraction, injury or surgery?
Do you carry a medical warning card?
Do you ever get cold sores?
Do you had jaundice, liver, kidney disease or hepatitis?
Additional Info
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