Dental Medical Record Form

Please complete all required fields and submit

Personal Details

Are you a new or Existing patient *

New Patient

Existing Patient

Title *

Mr

Mrs

Miss

Ms

Other Other

First Name *

Last Name *

Gender *

Male

Female

Your Personal Choice Your Personal Choice

Your Date of Birth * +

Email Address *

Address

Post Code

Home Tel No.

Mobile No.

Work No.

Occupation

Emergency Contact

By completing this section you acknowledge that you next of kin may be contacted in case of a medical emergency

Name & Surname

Tel No.

Relationship to You

GP Surgery Information

By completing this section you acknowledge that you next of kin may be contacted in case of a medical emergency

GP Clinic Name and Address

GP Name and Surname

GP Tel No.

Coronavirus (Covid-19)

Have you been tested for COVID-19? *

Yes

No

If you have been tested for Covid-19 - what was your result? *

Not applicable	Positive
Negative	Unclear

Have you had a Covid-19 antibody test? *

Yes

No

If you had a Covid-19 antibody test what was your result? *

Not applicable	Positive
Negative	Unclear

Have you or anyone you live with travel outside the UK in the last two weeks? *

Yes

No

Do you currently have ANY of these symptoms: a new continuous cough, a high temperature,a loss of, or change in, your normal sense of taste or smell (anosmia) *

Yes

No

Has anyone in your household (including yourself) been diagnosed (tested positive) with Covid-19 in the last 14 days *

Yes

No

Covid-19 details

0/200 characters

Dental History

When did you last visit the dentist? *

Do you have any dental pain/problem at present? *

Yes

No

Are you anxious/uncomfortable/have a phobia visiting the dentist? *

Yes

No

Please add any relevant dental history here

0/200 characters

Which treatment/s are you interested in? *

Medical History - A

Are You Currently?

Pregnant or possibly pregnant? *

Yes

No

Receiving treatment from a doctor, hospital or clinic? *

Yes

No

Carrying a medical warning card? *

Yes

No

Taking any prescribed medicines? *

Yes

No

Please add any relevant information and list any medications that you are taking

0/200 characters

Medical History - B

Do You Suffer From?

Allergies to any medicines (e.g. penicillin)? *

Yes

No

Allergies or intolerance to any foods (e.g. nuts)? *

Yes

No

Allergies to any substances (e.g. latex/rubber)? *

Yes

No

Hay fever or eczema? *

Yes

No

Bronchitis, asthma or other chest condition? *

Yes

No

Epilepsy / Fits? *

Yes

No

Fainting attacks, giddiness, blackouts? *

Yes

No

Muscle problems (e.g. myopathy, dystrophy, paralysis)? *

Yes

No

Heart problems (e.g. angina, blood pressure problems or stroke)? *

Yes

No

Diabetes (Type I/II or family history of diabetes)? *

Yes

No

Neurological diseases(e.g. Multiple Sclerosis)? *

Yes

No

Bleeding or blood disorders (haemophilia, easily bruising)? *

Yes

No

Stomach or bowel disease, ulcers/hiatus hernia/acid reflux? *

Yes

No

Any infectious diseases (e.g. Hepatitis, HIV, TB)? *

Yes

No

Please Add Further Details/Information

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Medical History - C

Have you Ever Had?

Rheumatic fever, heart murmur or chorea? *

Yes

No

Liver disease (e.g. jaundice, hepatitis)? *

Yes

No

Kidney disease? *

Yes

No

Any other serious illness? *

Yes

No

Blood refused by the Blood Transfusion Service? *

Yes

No

A bad reaction to general or local anaesthetic? *

Yes

No

A joint replaced or another implant/s? *

Yes

No

Treatment that required you to be in hospital? *

Yes

No

Heart surgery? *

Yes

No

Brain surgery *

Yes

No

Growth hormone treatment? *

Yes

No

A close relative with Creutzfeldt jakob Disease (CJD)? *

Yes

No

Steroid treatment *

Yes

No

Further Details on Medical Background

0/200 characters

Medical History - D

Drinking, Smoking and Chewing

How many units of alcohol do you drink per week?
(1 unit = 1/2 pint of lager, a small glass of wine, a single measure of spirit) *

0	1-2	3-5
6-9	>10

Do you smoke any tobacco products? *

Yes

No

In the past

Do you chew tobacco, pan, use gutkha or supar *

Yes

No

In the past

If applicable indicate amount smoked e.g. times per day

0/150 characters

Additional Comments or Details

Provide any other details which your dentist might need to know about
e.g. self-prescribed medicines such as aspirin

0/200 characters

GDPR - Medical Record & Treatment Consent

Our dental practice is bound by the General Data Protection Regulation (GDPR) 2018

I consent for the detail provided to be used:

Within the practice for the purposes of clinical care
With dental or medical colleagues outside the practice such as anaesthetists, dental or medical colleagues, scanning centres, dental laboratories and other third parties directly involved with or advising on my clinical care.

Please note that answering "No" will mean that we are unable to accept you as a patient

Consent for use of clinical data for treatment *

Yes

No

Consent to Use Images/Videos

As part of your treatment, we may take photograph or video your treatment
Images may be also be used anonymously for the purposes of teaching, conference presentation, website, articles or promotional material, in the UK and abroad.

Please indicate how we may be able to use any of your treatment images/videos?

Consent for use of clinical images and videos *

I consent to all images being used anonymously

I consent to all images being used anonymously apart from those where a substantial or identifiable part of my face is shown

I do not consent to any images being used outside the purposes of my clinical care

Completed By

Who completed this form *

Completed Date +

Signature of person filling out the form *

clear

Check-up	Hygiene	Veneers/Lumineers	Dental Implants	Smile Makeover
Root Canal	Teeth Whitening	Fillers/Botox	Orthodontics	Invisalign
Other Other