Oxshott Dental, Winkfield, Oxshott, Steel's Ln, KT22 0RD01372 843552Mon - Fri: 8:00AM - 5:00PM

Medical History Form

    All required boxes MUST be completed

     

    Title (required)

    Your Name (required)

    Date of Birth (required)

    Your Email (required)

    Address (required)

    Mobile Number (required)

    Home Number

    Occupation

    Name of GP (required)

    GP Telephone Number (required)

    Address of GP (required)

    Next of Kin (required)

    Next of Kin Telephone Number (required)

    Do you suffer from headaches? (required)
    YESNO

    Do you suffer from high blood pressure? (required)
    YESNO

    Do you or any close relative suffer from diabetes? (required)
    YESNO

    Did you have rheumatic fever as a child? (required)
    YESNO

    Do you suffer from epilepsy? (required)
    YESNO

    Ladies only, are you pregnant? (required)
    YESNO

    Do you have any reason to suspect you may carry HIV, hepatitis B or C? (required)
    YESNO

    Do you have any chest/lung problems? (required)
    YESNO

    If yes, please give details;

    Do you have any allergies? (required)
    YESNO

    If yes, please list here;

    Do you suffer from any heart problems (required)
    YESNO

    If yes, please give details;

    Have you ever been admitted to hospital for any operations or observations? (required)
    YESNO

    If yes, please give details;

    Have you had a blood test for any reason in the last 15 years? (required)
    YESNO

    If yes, for what reason;

    Do you suffer from any other medical condition? (required)
    YESNO

    If yes, please give details;

    Are you taking any medication prescribed by a doctor or specialist? (required)
    YESNO

    If yes, please list here;

    Do you smoke any tobacco products? (required)
    YESNO

    If yes, number per day;

     

    Dental History

    Name of Last Dentist

    Approximate date of last dental visit:

    Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches?
    YESNO
     

    Referred By:

    GoogleStreet SignAnother Patient/FriendOther
    Please Specify:

     
    Would you be interested in our facial aesthetic treatments?
    YESNO

    Would you be interested in our well-being treatments - Vitamin treatments (infusions and shots) / PRP for hair restoration?
    YESNO
     

    Smile Check

    Do you avoid smiling because you are embarrassed by your smile?
    YESNO

    Do you have crowded teeth?
    YESNO

    Would you like brighter or whiter teeth?
    YESNO

    Do you have any missing teeth?
    YESNO

    Do you have any broken or chipped teeth?
    YESNO

      

    I consent for Oxshott Dental to send me reminders by Text message and or email:
    YESNO

    I consent to be given details of my appointment times, planned treatments and costs Accepted

    I understand a fee will be charged if an appointment is broken or cancelled without 48 hours notice. Accepted

    I understand I can withdraw my consent at any time Accepted

    So that we can allocate sufficient time for your appointment, please indicate what the nature of your problem is, or what you would like us todo:

    I consent to treatment Accepted

    Signature