Medical History

It is important for the Dentist to know details about your medical history as this could affect the success of your dental treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the reverse of this form.

Personal Details
We'll never share your email with anyone else.
Medical History
I have confidential medical information that I do not wish to write down. I would prefer to speak to the dentist.
Are you receiving any medical treatment at the present time?
Have you been hospitalised in the last 12 months?
Have you had any abnormal reactions to local or general anaesthesia?
Do you require antibiotic cover before dental treatment?
Do you take any blood thinners?
Do you Smoke?
Are you pregnant?
Existing Conditions

Do you have, or have you ever had any of the following medical conditions?
If so please tick as appropriate

Dental History
How did you hear about us?
Patient Rights and Responsibilites
I have read and accept the patient's rights and responsibilities