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



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).
Yes


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.
Yes


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.
Yes


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.
Confirm information is correct


Medical Questions

Are You

Are you pregnant?
YesNo

Are you receiving treatment from a doctor, hospital or clinic?
YesNo

Are you taking any medicines?
YesNo


Have You

Have you any infection or disease including HIV and Hepatitis?
YesNo

Have you allergies to any medicines and materials?
YesNo

Have you hayfever or eczema?
YesNo

Have you bronchitis, asthma or chest condition?
YesNo

Have you any heart problems including angina, blood pressure?
YesNo

Have you diabetes (or does anyone in the family)?
YesNo

Have you arthritis?
YesNo

Have you bruising of persistent bleeding?
YesNo

Have you had a stroke?
YesNo

Have you any fainting, giddiness or epilepsy?
YesNo

Have you rheumatic fever?
YesNo

Have you had liver disease (including jaundice and hepatitis)?
YesNo

Have you had kidney disease?
YesNo

Have you been hospitalised?
YesNo

Have you had a bad reaction to anaesthetic?
YesNo

Have you smoked?
YesNo

Have you any other condition we should know about?
YesNo


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.