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; 
 

Do you drink alcohol? (required) 
YESNO 

If yes, number units per week; 
 

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