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Special Offers!
5 Vale Parade, Kingston Vale, London SW15 3PS
Open 7 days a week from 8am to 11pm
0208 547 9997
Free Cosmetic Consultation Up to 3 Year 0% Finance
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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
………………………………………………………………………………………………………………………………

Latest Patient Reviews

  • Pearl Dental Clinic

    Friendly staff, who remember you.

    05/04/2014
  • Pearl Dental Clinic

    I am a nervous dental patient but was made to feel reasonably relaxed.

    28/03/2014
  • Pearl Dental Clinic

    DR Ehsan is a very good dentist

    16/03/2014
  • Pearl Dental Clinic

    Good customer service

    14/03/2014
  • Pearl Dental Clinic

    My favourite part of Pearl Dental Clinic is my clinician, Dr Ehsan Esfahani. Dr Esfahani is very good at explaining my current status and my future treatment plan (Invisalign Full) he gives me great assurance and confidence that the outcome of my treatment will be as promised in my first consultation - Dr Esfahani is reluctant to make promises that he knows cannot be delivered. In addition to his excellent dentistry knowledge and professional manner Dr Esfahani is a genuinely nice person who is very welcoming, relaxing and a pleasure to have as my dentist. I should also thank Dr Esfahani's assistant and the gentleman on the front desk (Wednesday nights) who are both incredibly polite and helpful during every visit to the practice.

    13/03/2014
  • Pearl Dental Clinic

    Value for money

    13/03/2014
  • Pearl Dental Clinic

    Great treatment and service provided by the Doctors/Assistants, friendliness of the reception staff and convenient opening hours and flexibility.

    10/03/2014
  • Pearl Dental Clinic

    Patience and caring attitude

    10/03/2014
  • Pearl Dental Clinic

    Patience and friendliness

    10/03/2014
  • Pearl Dental Clinic

    Extended opening hours; dentist available on weekends which is great for working people like myself. Very friendly, helpful and approachable staff. Easy to book/alter appointments. Very professional service. Reasonable prices compared to other dental practises. Would highly recommend.

    09/03/2014
  • Pearl Dental Clinic

    dr mohsen is amazing n really nice mashaAllah

    02/03/2014
  • Pearl Dental Clinic

    Your expertise and good customer service

    27/02/2014
  • Pearl Dental Clinic

    Efficient friendly organised excellent opening hours and value for money

    19/02/2014
  • Pearl Dental Clinic

    Friendly staff

    16/02/2014
  • Pearl Dental Clinic

    The staff are very nice, its also clean. I used to have a fear or dental work but I'm slowly getting better as the staff here don't put pressure on you or make you feel bad about your fears, your always just encouraged to try your best. They alway apriciate that you are trying your best.

    09/02/2014
  • Pearl Dental Clinic

    Good deal with Invisalign. Very good opening hours. Finance.

    09/02/2014
  • Pearl Dental Clinic

    Very efficient

    03/02/2014
  • Pearl Dental Clinic

    I would like to thank my dentist Vahid Motahar for my fantastic treatment iv been receiving I have always been a nervous patient as I hate the dentist but really wanted braces for some time, when I had my first consultation with Mr Motahar I felt confident he was good so went ahead with treatment. I am now half way through and my teeth are looking great already. I would like to thank Mr Motahar and the team for making this process a much better experience for me.

    28/01/2014
  • Pearl Dental Clinic

    No waiting. Very punctual. Easy to get an appointment. Appointment reminders.

    27/01/2014
  • Pearl Dental Clinic

    Very clean practice and friendly staff. Would definitely return in future

    19/01/2014