Patient details

Full name*

Preferred name

Date of birth*

Address*

Mobile*

Email*

Preferred method of contact*
PhoneEmailSMS

Emergency contact

Emergency contact name*

Relationship*

Emergency contact phone*

GP details (optional)

GP name

GP practice

GP phone

Medical history

Do you have any medical conditions?*
YesNo

Please list any medical conditions (if applicable)

Are you currently taking any medication?*
YesNo

Please list any medications (if applicable)

Do you have any allergies (including latex)?*
YesNo

Please list any allergies (if applicable)

Do you take blood thinners (e.g. warfarin, apixaban, rivaroxaban, clopidogrel)?
YesNoNot sure

Have you ever been advised you need antibiotics before dental treatment?
YesNoNot sure

Relevant medical factors (tick any that apply)
DiabetesHeart conditionHigh blood pressureAsthma/COPDEpilepsyImmune condition / immunosuppressedHistory of endocarditisJoint replacementBleeding disorderNone of the above

Smoking / vaping status*
Non-smokerSmokerVapeEx-smoker

If applicable, approximate amount/frequency

Are you pregnant or breastfeeding? (if applicable)
YesNoNot applicable

Dental history

What brings you in today? What would you like help with?*

Do you feel anxious about dental treatment?
YesNoSometimes

If yes/sometimes, what helps?

Date of last dental visit (approx.)

Have you ever had any complications with dental treatment or anaesthetic?
YesNo

If yes, please describe

Consent

I confirm that the information provided is accurate to the best of my knowledge.

I consent to the practice storing and processing my personal and health information for the purposes of providing dental care, in line with the Privacy Policy.

I would like to receive occasional practice updates (optional).