Medical History Form

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Patient Information

Preferred Channels of Communication

Please can you tick the relevant boxes to confirm your preferred channels of communication and that you consent to us using these to contact you. (Please note that e mails sent and received from unsecured e mail accounts may be accessible by third parties.)

We will only use the above information in order to remain in communication with you, remind you about appointment times, when dental check-ups and hygienist visits are due and for invoicing and payment purposes. We will not share any personal information with third parties without your prior consent and this will only be in relation to specific medical/dental healthcare pathways. We will never share your personal information for the purposes of advertising or marketing. Our data protection policies are available to view here. Please tick the consent box below if you consent to our use of your personal data as outlined above:

Details of General Medical Practitioner

Emergency Contact details

Coronavirus Screening

Have you been diagnosed with the coronavirus?


Have you been in contact with someone who has a confirmed case of coronavirus?


Are you or your household self-isolating?


Do you or have you had a temperature of 37.8 degrees C or above in the last 14 days?


Do you or have you had a dry, persistent cough in the last 14 days?


Have you noticed a loss of smell and/or taste in the last 14 days?


Are you in the shielded patient group?



Are you attending or receiving treatment from a doctor, hospital, clinic or specialist at present?


Are you currently taking any prescribed medicines? (e.g. tablets, ointments or inhalers, including contraceptives and hormone replacement therapy) - Please name the tablets etc


Are you carrying a medical warning card?


Are you pregnant?


Do you suffer from any allergies to medicines (e.g. penicillin, chlorhexadine), substances (e.g. latex or rubber) or foods?


Do you suffer from Hay fever or eczema?


Do you suffer from bronchitis, asthma, difficulty breathing or any other chest condition?


Have you had or do you suffer from fainting attacks, giddiness, blackouts or epilepsy?


Do you suffer from heart problems, angina, blood pressure problems or stroke?


Are you diabetic (or is anyone in your family)?


Do you suffer from arthritis?


Have you ever had a joint replacement or any other implant?


Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?


Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease?


Do you suffer from any infectious diseases (including HIV and hepatitis)?


Have you ever had blood refused by the Blood Transfusion Service?


Have you ever had a bad reaction to general or local anaesthetic?


Have you ever had treatment that required you to stay in hospital?


Have you ever had heart surgery?


Do you regularly drink more than 21 units of alcohol per week?


Do you smoke any tobacco products now (or did you in the past)?


Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)?


Have you ever had any other serious illness?


Do you have any close relatives (parent, sibling, child, grandparent or grandchild) with Creutzfeldt jakob disease?


Is there any other information which your dentist might need to know about, such as self-prescribed medicines (e.g. aspirin)?


Are you concerned about your skin complexion?


Are you concerned about fine lines and wrinkles?


Are you concerned about loss of volume?


Dental Treatment Consent During COVID 19

Thank you for your continued trust in our practice. As with any transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as ‘Coronavirus’ at any time, or in any place. Be assured that we will continue to follow all recommended government scientific guidance and use thorough personal protective equipment (PPE) and disinfectant protocols to limit transmission of all diseases.

Despite our careful attention to strengthen disinfection and the use of personal barriers, there’s is still a chance you could be exposed to an illness at the surgery, just as you might be whilst shopping. Nationwide social distancing has reduced the transmission of the coronavirus. Although we have taken measures to enable social distancing in our practice, due to the nature of the procedure, it is not possible to maintain social distancing between the patient, dental health care team members and sometimes other patients, at all times.

Although exposure is unlikely do you accept the risk of consent to treatment? *


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