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New Patient Medical History Form

Please complete this form before your treatment. We are dedicated to providing the highest standard of dental care for your entire family. We are pleased to offer free treatment for children under 10 when a parent is registered and attends regular dental examinations.

We offer 10 year warranty for our dental work , except our specialist treatments.

Medical Form

Date of Birth
Day
Month
Year
Sex/ Gender
Are you currently under the care of a doctor, hospital or clinic?
Do you carry a medical warning card?
Is your BMI over 30?
Do you smoke?
Do you chew tobacco products?
Do you drink alcohol? (If yes, how many units per week- a unit is 1/2 pint larger, a single spirit or small glass of wine)
Medical Conditions- Please tick all that apply
Do you tend to bleed excessively after injury or extraction?
Do you bruise spontaneously?
Have you ever had sedation or a general anaesthetic?
Have you ever had a reaction to local or general anaesthetic?
Do you have difficulty lying flat?
Have you ever fainted?
Do you have any allergies to medicines (e.g. antibiotics), substances (e.g. latex) or foods?
Current Medication- please tick all that apply
Choose from below:
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