Dental Medical Record Form

Please complete all required fields and submit

Personal Details

Are you a new or Existing patient *
Title *
Gender *

Emergency Contact

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

GP Surgery Information

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

Coronavirus (Covid-19)

Have you been tested for COVID-19? *
If you have been tested for Covid-19 - what was your result? *
Have you had a Covid-19 antibody test? *
If you had a Covid-19 antibody test what was your result? *
Have you or anyone you live with travel outside the UK in the last two weeks? *
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) *
Has anyone in your household (including yourself) been diagnosed (tested positive) with Covid-19 in the last 14 days *
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Dental History

When did you last visit the dentist? *
Do you have any dental pain/problem at present? *
Are you anxious/uncomfortable/have a phobia visiting the dentist? *
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Which treatment/s are you interested in? *

Medical History - A

Are You Currently?
Pregnant or possibly pregnant? *
Receiving treatment from a doctor, hospital or clinic? *
Carrying a medical warning card? *
Taking any prescribed medicines? *
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Medical History - B

Do You Suffer From?
Allergies to any medicines (e.g. penicillin)? *
Allergies or intolerance to any foods (e.g. nuts)? *
Allergies to any substances (e.g. latex/rubber)? *
Hay fever or eczema? *
Bronchitis, asthma or other chest condition? *
Epilepsy / Fits? *
Fainting attacks, giddiness, blackouts? *
Muscle problems (e.g. myopathy, dystrophy, paralysis)? *
Heart problems (e.g. angina, blood pressure problems or stroke)? *
Diabetes (Type I/II or family history of diabetes)? *
Neurological diseases(e.g. Multiple Sclerosis)? *
Bleeding or blood disorders (haemophilia, easily bruising)? *
Stomach or bowel disease, ulcers/hiatus hernia/acid reflux? *
Any infectious diseases (e.g. Hepatitis, HIV, TB)? *
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Medical History - C

Have you Ever Had?
Rheumatic fever, heart murmur or chorea? *
Liver disease (e.g. jaundice, hepatitis)? *
Kidney disease? *
Any other serious illness? *
Blood refused by the Blood Transfusion Service? *
A bad reaction to general or local anaesthetic? *
A joint replaced or another implant/s? *
Treatment that required you to be in hospital? *
Heart surgery? *
Brain surgery *
Growth hormone treatment? *
A close relative with Creutzfeldt jakob Disease (CJD)? *
Steroid treatment *
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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) *
Do you smoke any tobacco products? *
Do you chew tobacco, pan, use gutkha or supar *
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Additional Comments or Details

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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 *

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 *

Completed By

Who completed this form *
Signature of person filling out the form *