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Medical history

Surname ( Mr / Mrs / Miss / Ms / Mst ): …………………………………………..
Forename: …………………………………………..
Address: …………………………………………..
Postcode: …………………………. Date of Birth: ………………………….
Tel (home): …………………………. Tel (business): ………………………….
Occupation: ……………. Mobile: ……………….
Email*: …………………………………………..
Last Dental Check-up: …………………… Last Dental Hygiene: ……………………..

Certain medical conditions can affect dental treatment and vice versa

Please complete this form by ticking the appropriate boxes and answering the questions. All details will be strictly confidential.

Do you have or have you suffered from:

YES NO

Rheumatic fever [ ]    [ ]
Any heart complaint, heart surgery or stroke [ ]    [ ]
Diabetes [ ]    [ ]
Epilepsy or fainting attacks [ ]    [ ]
Chronic bronchitis or asthma [ ]    [ ]
Hepatitis [ ]    [ ]
Excessive bleeding [ ]    [ ]
High blood pressure [ ]    [ ]
Any other serious illness [ ]    [ ]
Do you carry a medical warning card [ ]    [ ]

Are you:

  • Allergic to any medicine, tablets, substances, or latex? (list below)
[ ]    [ ]
  • Allergic to any medicine, tablets, substances, or latex? (list below)
[ ]    [ ]
  • At present taking any medicine or tablets? (list below)
[ ]    [ ]
Pregnant? [ ]    [ ]

In the past 2 years:

  • Have you undergone any operations?
[ ]    [ ]
  • Been treated with hydro-cortisone or corticosteroids?
[ ]    [ ]
Have you ever had a joint replacement operation? [ ]    [ ]
Please tick or tell the Dentist if you are HIV positive [ ]    [ ]
What is your average weekly consumption of alcohol? [ ]    [ ]
If you smoke, what is your average per week? [ ]    [ ]

If yes to any of the above questions, please supply details in ‘Notes’ below or use back of form

Name and address of your GP:
………………………………………………..
………………………………………………..
………………………………………………..
Notes:
………………………………………………..
………………………………………………..
………………………………………………..

If you are not sure of any of the questions, or if your medical circumstances change, please inform your Dentist.

Patient’s signature: ……………………………….. Date: ……………….
Have you had Cosmetic Dentistry in the past? Yes / No
If ‘Yes’ please give brief details below
………………………………………………………………………………………………….

Why are you considering Cosmetic Dentistry? (please tick 1 or more of the following)

[ ] I am generally unhappy with my smile.
[ ] I have discoloured/stained teeth.
[ ] I have crooked or misaligned teeth.
[ ] I have a gummy smile.
[ ] I have missing teeth.
[ ] Other…………………………………

How long have you been considering Cosmetic Dentistry? (please tick 1 or more of the following)

[ ] Less than 1 month.
[ ] Less than 1 year.
[ ] More than 1 year.

Why have you chosen now to have Cosmetic Dentistry? (please tick 1 or more of the following)

[ ] Upcoming special occasion or career opportunity.
[ ] Availability of desired treatment. (unaware of treatment options in the past)
[ ] Prompted by friend/colleague or family member.
[ ] Done research and feel ready.
[ ] Finances.
[ ] Other…………………………………

Would you like to take advantage of any of our treatment financing facilities[ ] Yes / No

If ‘Yes’ please answer these simple questions to check eligibility:

1. Are you in permanent full/part time employment? Yes / No
2. Have you been resident in the UK for 1 year or longer? Yes / No
3. Are you in a permanent place of residence at present? Yes / No
4. Do you hold a UK bank account with Direct Debit facility? Yes / No
5. Are you a homeowner? Yes / No

Why have you chosen us for your consultation today? (please tick 1 or more of the following)

[ ] Conveniently located.
[ ] Flexible and easily available appointment times.
[ ] Recommended by a colleague/friend or family member.
[ ] Pearl Dental Clinic website / Range of treatments and facilities available at the clinic.
[ ] Other…………………………………

How did you hear about Pearl Dental Clinic?

[ ] Google
[ ] Referred by friend/colleague or family member.
[ ] Referred by my Dentist.
[ ] Other…………………………………

Are you currently undergoing any other Dental treatment? Yes / No

If ‘Yes’ please give brief details below
………………………………………………………………………………………………………………………………

Below are some genuine reviews of our services from independent sources

Reputation Reviews