Download Llandeilo Dental Practice

Completed by:
Self
llan
deilo
Guardian
Parent
dental practice
Patient’s
Signature:
Date:
/
/
Dentist’s
Signature:
Date:
/
/
Electronic Privacy
The practice regularly communicates with its patients by email and
texts to confirm appointments and costs of treatment.
For you to benefit from receiving these communications, we
require your permission. If you choose not to agree, you will not
receive emails or texts from us.
Confidential Medical History Form
We ask you for information about your general health to help us treat
you safely. Please write your contact details below, answer the health
questions inside then sign the form on the back page. We will use this
form at later visits to discuss any change in your general health. All
information will be kept strictly confidential by the people caring for
you.
Surname:   
First Name/s:
We will not pass on your contact details to third parties, We will
also not send any information regarded as personal - for example,
information about treatments and plans.
Title:
I agree that Llandeilo Dental Practice may use my email
address and mobile phone number to contact me regarding
appointments and related information. Such communications
may include information relating to products and services of the
practice. I understand that I can opt out from receiving these
communications at any time.
Address:
Patient’s
Signature:
Date:
llan
deilo
dental practice
/
/
Sex: Male
Date of Birth:
/
/
Postcode:
Home Telephone:
Mobile:
Emergency Contact: Name:
Number:
E-mail:
Occupation:
Doctors Name
&
Address:
Doctor’s Telephone:
Female
Are you currently:
Receiving treatment from a
doctor, hospital or clinic?
Yes
No
Give Details
Taking any prescribed
medicines (eg, tablets,
ointments, injections
or inhalers, including
contraceptives and hormone
replacement therapy)?
Carrying a medical warning
card?
Pregnant or possibly
pregnant?
Alcohol:
How many units of alcohol do you drink per week?
Have you ever suffered from:
Allergies to medicines (eg.
Penicillin), substances (eg.
Latex) or foods?
Bronchitis, asthma or other
chest conditions?
Fainting attacks, giddiness,
blackouts or epilepsy?
Heart problems, angina,
blood pressure problems or
stroke?
Heart Surgery?
Bone or joint disease?
Bruising or persistent
bleeding following injury,
tooth extraction or surgery?
Any other serious illness or
infectious disease?
Liver disease (eg. Jaundice,
hepatitis) or kidney disease?
Blood refused by the Blood
Transfusion Service?
A bad reaction to general or
local anaesthetic?
Treatment that required you
to be in hospital?
Diabetes (or does anyone in
your family)?
Yes
No
Give Details
(A unit is half a pint of lager, a single measure of spirits or a small glass
of wine/aperitif)
units per week
Tobacco use:
Do you smoke any tobacco
products now or in the past?
Yes
No
In the Past
times per day
Do you chew tobacco, pan,
use gutkha or supari now or
in the past?
times per day
Please give any other details which your dentist might need to
know, such as self-prescribed medicines (eg. Aspirin) or any
disabilities.