Medical History Form

Which is your preferred contact method for appointment reminders?

Are you receiving any medical treatment at the present time?*

Have you been a patient in hospital during the past two years?*

Do you take any medicine tablets, capsules or drugs at the moment?*

Do you have a disability or long term health condition that you feel would require us to make reasonable adjustments? If yes, please tell us what facilities / adjustments / equipment you may require?

Do you have any allergies, including any unusual effects from any tablets, drugs, injections or anaesthetic?*

Have you ever had any of the following? If so, please tick as appropriate.

Have you had any prosthetic surgery? (E.g. Heart Valve or Hip Replacement)*

Is there any other relevant medical information you feel your dentist should know?

Woman: Are you pregnant?

Do you smoke/vape?*

Do you drink alcohol?

How did you find us?

I agree that Chase Side Dental Practice may use my mobile & email address to contact me regarding appointments and related information about my treatment and to send copies of referral letters. I understand that I can opt out of this by contacting the practice. I give permission for my dentist to send digital communications (x-rays and clinical photographs of my teeth) when referring me to a specialist*