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FACIAL AESTHETICS
WRINKLE RELAZING
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AFFILIATE DISCOUNT
BLOG
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HOME
PRACTICE
ABOUT
TEAM
TREATMENTS
DENTISTRY
GENERAL DENTISTRY
SEDATION
DENTAL FILLINGS
FAMILY DENTISTRY
EMERGENCY DENTIST
DENTAL HYGIENIEST
DENTAL IMPLANTS
DENTAL IMPLANTS
ALL ON 4
COSMETIC DENTISRY
COSMETIC DENTISTRY
SMILE MAKEOVER
MAC VENEERS
MOUTH GUARD
PORCELAIN VENEERS
TEETH WHITENING
FACIAL AESTHETICS
FACIAL AESTHETICS
WRINKLE RELAZING
DERMAL FILLERS
DERMAROLLER
HEART LIPS™
MESOTHERAPY
CHEMICAL PEELS
OBAGI
ORTHODONTICS
ORTHO TREATMENT
6 MONTHS SMILES
DAMON BRACES
INCOGNITO™ LINGUAL BRACES
INMAN ALIGNER™
INVISALIGN®
INVISALIGN TEEN®
INVISALIGN LITE®
SIMPLI5
PATIENT
MEDICAL HISTORY
PATIENT SCREENING
FEES
DENTAL PAYMENT PLAN
FAQ
REFER A FRIEND
AFFILIATE DISCOUNT
BLOG
CONTACT
Medical and Dental History
(Mr/Mrs/Miss/Ms) Surname
Forename
D.O.B
Address
Postcode
Tel no (Home/Work/Mobile)
Email Address
Name & Address of Dentist
Name & Address of Doctor
Please complete this form by ticking the appropriate boxes and answering the questions;
All details will be strictly confidential.
Do you or have you ever suffered from:
Rheumatic fever?
Yes
No
Any heart complaint (including heart murmur)?
Yes
No
Diabetes?
Yes
No
Epilepsy?
Yes
No
Asthma?
Yes
No
Hay Fever?
Yes
No
Hepatitis?
Yes
No
Jaundice?
Yes
No
Excessive bleeding?
Yes
No
High blood pressure?
Yes
No
Are you allergic to any medicines or materials? (If yes, please give details)
Yes
No
Are you at present taking any medication? (If yes, please give details)
Yes
No
Have you; had any serious illnesses or operations? (If yes, please give details)
Yes
No
Have you; had any previous Orthodontic Treatment? (If yes, please give details below)
Yes
No
Are you or is there a possibility you could be pregnant?
Yes
No
Are you a smoker, if yes how many cigarettes do you smoke per day?
Yes
No
Approximate units of alcohol consumed per week?
Do you grind or clench your teeth? If yes, we strongly advise you to use a mouthguard.
Yes
No
Do you play any contact sports? If yes, we strongly advise you to use a mouthguard.
Yes
No
How did you hear about us?
Signature
Date
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