Download Date: - Beautiful Smile Dental Surgery

WELCOME TO BEAUTIFUL SMILE DENTAL SURGERY
In order to render treatment of a high standard, it is necessary to have the following information
which will be handled confidentially. Please fill in the following form completely.
NAME: Surname……………………………
First Name…………………………………….
HOME ADDRESS: ………………………………………………………………………………..
POSTCODE:..……………………………………HOME.TELEPHONE: ……………………….
BUSINESS.TELEPHONE: ………………………MOBILE.TELEPHONE: ……………………
EMAIL ADDRESS………………………………………………………………………………..
DATE OF BIRTH: ……………………MARITAL STATUS:. …………………………….
NAME OF EMPLOYER: ………………………………………………………………………….
BUSINESS ADDRESS: ……………………………………………………………………………
WHOM MAY WE THANK FOR REFERRING YOU TO US ?…………………………………
NAME OF HEALTH FUND IN ANY DENTAL COVER: ………………………………………
MEDICAL INFORMATION
 Have you had or are you suffering from
YES NO
 Heart disease or high blood pressure? ……………………………………………..
 Diabetes, Rheumatic Fever, Hyperthyroidism, Asthma, Anaemia? ………………
 Liver Disease e.g. Hepatitis? …………………………………………
 Excessive Bleeding? ………………………………………………………………………….
 AIDS/ HIV……………………………………………………………………………………
 Are you in an AIDS/HIV high risk category (Homosexual, Bisexual, Intravenous drug user)? …
 Do you require antibiotic therapy for any condition prior to undergoing dental treatment? …
 Are you allergic to any drugs or antiseptics (especially penicillin)? If so please specify…………
 Are you at present taking any drugs, medicines, having injections or attending a Doctor? ……
If so please specify: ……………………………………………………………………..
 Have you had any other serious illnesses or accidents in the past? If so please specify: ……
 If pregnant, please state how many months………………………..
 Do you smoke? ………………………………………………………………………………..
DENTAL INFORMATION
If you will be kind enough to answer the following questions it will help us to help you more.
Is there anything in particular you want the dentist to look at today? ………………………………….
How long has it been since your last dental check up? …………………………………………………
Do you like the appearance of your teeth /your smile? …………..……………………………………..
Are your teeth all in alignment/straight? ……………………………………………………………..
Do you have spaces that you don’t like to look at? ……………………………………………………..
Do you like the colour of your teeth? ……………………………………………………………………
Do you like the shape of your teeth? …………………………………………………………………….
Are your teeth chipped/hidden/protruding? ……………………………………………………………..
Do you like the way your teeth come together? …………………………………………………………
Are there any old fillings or dental work that you don’t like to look at? ……………………………….
What would you most like to change about the appearance of your teeth? ………………………….…
Do your gums bleed when you brush your teeth? ……………………………………………………
Do you play contact sports? …………………………………………………………………………….
I understand that I am personally responsible for all dental services rendered to me/above person.
SIGNATURE…………………………………… DATE………………………………………