First Name (required)
Date of Birth
If you are under 16, please name a parent/guardian
Have you ever had any of the following? Please tick those that apply:
Who is your usual GP?
Are you currently taking any medication?
Are you currently undergoing medical treatment?
Do you smoke?
Ladies, are you pregnant?
If yes, when are you due
Are you allergic to any medication or materials? i.e Penicillin. Latex?
Is there anything else you would like to tell us about your general health?
What brings you to our practice today?
When was your last dental visit?
Please tick any dental concerns that you have:
Do you feel nervous about your dental treatment?
Do you usually require antibiotics before dental treatment?
Have you ever had any adverse reaction to dental treatment?
Have you had your wisdom teeth removed?
Are you interested in whitening or cosmetic treatment?
How did you hear about us?
If you were referred here today, whom can we thank?
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