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Medical History Form

Patient Information

Preferred Channels of Communication

Please can you tick the relevant boxes to confirm your preferred channels of communication and that you consent to us using these to contact you. (Please note that e mails sent and received from unsecured e mail accounts may be accessible by third parties.) Required
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 on our Privacy Policy Page. Please tick the consent box below if you consent to our use of your personal data as outline above. Required
Our dentists are involved in dental education, they lecture both nationally and internationally and write articles in dental journals and publications. As part of your ongoing dental care we will take x rays and we may take clinical photos but these will always be anonymised. If you are happy for us to use your x-rays, photos and/or clinical records for teaching purposes please can we ask you to tick the box below as a confirmation of your consent. You are always at liberty to withdraw this consent at any stage, which you can do so by informing us in writing. Required

Confidential Medical History 

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist at present? Required
Are you allergic to any medicines, foods or materials? (please specify) Do you suffer from hayfever or eczema? Required
Have you had a bad reaction to a local anaesthetic or any other material in the dental setting? Required
Do you currently smoke? Required
Have you smoked in the past? Required
Do you drink Alcohol? Required
Have you suffered from or do you currently suffer from any infectious disease e.g Viral Hepatitis, HIV, COVID-19? Required
Do you have or have you had a heart murmur, a heart valve replacement, rheumatic fever and/or infective endocarditis? Required
Have you been advised that you need to take antibiotics prior to dental treatment? Required
Do you suffer from heart disease, angina, high blood pressure, irregular heartbeat? Required
Have you had a heart attack in the past? Required
Do you have an increased risk of bleeding and/or bruising? Required
Have you in the past or do you currently suffer from Osteoporosis? Required
Do you suffer from Diabetes? Required
Have you had or are you currently having treatment for cancer? Required
Have you had or do you have jaundice, Liver disease (hepatitis, cirrhosis), or Kidney disease? Required
Do you suffer from bronchitis, asthma, difficulty breathing or any other chest condition? Required
Do you suffer from impaired hearing? Required
Are you pregnant? Required
Are you breastfeeding? Required
Are you using an oral contraceptive pill? Required
Have you had or do you suffer from fainting attacks, giddiness, blackouts or epilepsy? Required
Are there any other aspects concerning your general medical health that we should know about? Required

Details of General Medical Practitioner

Emergency Contact details

Thank you for submitting this form.

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