Date of Birth
Home telephone number *
Work telephone number *
Mobile telephone number
Please can you tick the relevant boxes to confirm how you would like to be contacted and that you consent to us using these details 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 outline above:
Are you attending or receiving treatment from a doctor, hospital, clinic or specialist at present?
If YES please give treatment details
Are you allergic to any medicines, foods or materials? (please specify)
Do you suffer from hayfever or eczema?
If YES please give allergy details
Have you had a bad reaction to a local anaesthetic or any other material in the dental setting?
If YES please give reaction details
Do you currently smoke?
If yes, How long have you smoked for? How much do you smoke per day? What do you smoke e.g Cigarettes, Cigars, Vape?
Have you smoked in the past?
If yes, how long did you smoke for, when did you stop smoking and what did you smoke?
Do you drink Alcohol?
Have you suffered from or do you currently suffer from any infectious disease e.g Viral Hepatitis, HIV, COVID-19?
Do you have or have you had a heart murmur, a heart valve replacement, rheumatic fever and/or infective endocarditis?
Have you been advised that you need to take antibiotics prior to dental treatment?
Do you suffer from heart disease, angina, high blood pressure, irregular heartbeat?
Have you had a heart attack in the past?
Do you have an increased risk of bleeding and/or bruising?
Have you in the past or do you currently suffer from Osteoporosis?
Do you suffer from Diabetes?
Have you had or are you currently having treatment for cancer?
Have you had or do you have jaundice, Liver disease (hepatitis, cirrhosis), or Kidney disease?
Do you suffer from bronchitis, asthma, difficulty breathing or any other chest condition?
Do you suffer from impaired hearing?
Are you pregnant?
Are you breastfeeding?
Are you using an oral contraceptive pill?
Have you had or do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
Are there any other aspects concerning your general medical health that we should know about?
Please provide a comprehensive list of all medications that you are currently taking.
GP Telephone Number
Emergency Contact Name
Emergency Contact Telephone Number
Relationship to patient
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Restorative Dentistry & Dental Implantology