Confidential Medical History Form

Please fill in the form below in full, when finished, simply click the green submit form button at the bottom of the page.

Personal and Doctors Details

Medical Questions

Are you...
Have you...

Consents and Disclaimer

Our patients appreciate appointment reminders sent by text message. If you would prefer NOT to receive these messages you may opt out by ticking this box (but please remember that we do charge for wasted surgery time).
Our specialists are actively involved in research and education. Patients are usually pleased to allow us to use records while maintaining anonymity. If you prefer us NOT to use your records in this way please tick the box.
We have provided you with full information including terms and conditions of payment through our website and leaflets. If you feel uncertain about any aspect please tick here for a member of staff to contact you.
To the best of my knowledge this information is correct and I give my permission for the dentist or anaesthetist to contact my doctor and to check any medical record available.
Data Protection

We take your and the privacy of our patients very seriously and have policies, procedures and the infrastructure in place to protect any information and documents provided to us. We are fully complaint with the GDPR legislation and other applicable data protection regulations. For more information, please click here to view our full privacy policy.