Page 1
Page 2
Page 3

Name

Preferred title *

Mr Mrs Miss Ms Dr Prof

First name *

Last name *

Street address *

Postcode *

Email address *

Contact phone *

Date of birth *

Occupation

If you are aged under 16 please provide the following:

Name of your parent/guardian

Address of your parent/guardian

When did you last visit a dentist?

What is the name of your previous dentist?

How did you hear about us?

Do you have dental insurance cover? *

Yes No

What is the name of your doctor/GP? *

Do you smoke? *

Yes No

Do you prefer:

Amalgam (silver) fillings

Composite (white, non-metal) fillings, if suitable

No preference, guided by dentist

I wish to discuss this with the dentist

Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice requires both patient and staff member to undertake a blood test.

Do you agree to a confidential blood test? *

Yes No I wish to discuss this with the dentist

Have you ever had any of the following: *

Heart attack

Heart murmur

Rheumatic fever

Open heart surgery

High blood pressure

Stroke

Asthma

Chest and lung disease

Sinus/hay fever

Epilepsy

Diabetes

Kidney problems

Gastric problems

Depressive illness

Radiotherapy

None of the above

Are you taking any tablets, medicines, pills or drugs? *

Yes No

Have you ever had any allergies to medicines, or other substances (such as Latex)? *

Yes No

Do you have an artificial or prosthetic joint? *

Yes No

Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time? *

Yes No

Have you ever had contact with *

HIV Virus Hepatitis B Virus Hepatitis C Virus None of these

Have you ever had an unfavourable reaction to an anaesthetic? *

Yes No

For women: are you pregnant now? *

Yes No

Are there any other health matters you need to talk to the dentist about? *

Yes No