Title
*
First Name
*
Last Name
*
Please list any medications you are currently taking: E.g. blood thinners etc.
Please list any allergies you have, including latex or any antbiotics
Are you currently pregnant?
Yes
No
Please declare if you suffer from any of the following medical conditions.
Heart Conditions
Valve Issue or Replacement
Stent Placement
Heart Failure
Heart Attack
Rheumatic Fever
Arrhythmia, Heart Murmur or Irregular Heart Beat
Angina
Stroke
Yes
No
Blood Conditions
Hypertension
Bleeding Disorder
Anaemia
Organ/Joint Transplant or Replacement
Yes
No
Diabetes
Type I
Type II
Cancer
Current
Previous
Gastrointestinal Disorder/Reflux
Yes
No
Respiratory Disorders
Asthma
COPD
Emphysema
Other
Epilepsy
Yes
No
Have you recently been hospitalised?
Yes
No
If so, please provide date and details.
Are you currently a smoker or have a history of smoking?
Current Smoker
Previous Smoker
Non Smoker
Do you suffer from any other medical conditions that have not been listed above, or is there anything else your dentist should know?
Have you ever required antibiotic cover prior to dental treatment?
Yes – please contact our surgery via phone
No
Please provide details for your GP or Specialist (Name, Place of Practice, Contact Number)
Please provide details for your Emergency Contact (Name, Contact Number, Relationship)
I declare that the information above is true.
*
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Submit