Patient Medical History

Your privacy

Capital Dental collects the information in this form so your dentist can treat you safely. It goes to the clinic you choose below and is used by that clinic's team to provide your care.

You don't have to fill this in online. If you'd prefer, arrive 10 minutes before your appointment and complete it at reception.

You can ask to see or correct the information we hold about you at any time by contacting your clinic. Read our privacy policy.

Address
Preferred Method of Communication
Do you wish to straighten your teeth or better your smile?
Do you wish to whiten your teeth?

Medical History

In order to provide the best and safest dental treatment, your clinician needs to know of any medical problems which may affect your treatment. Have you ever had any of the following:
Heart problems
Rheumatic Fever
Radiotherapy
High Blood Pressure
Stroke
Asthma
Chest & Lung Disease
Sinus/Hay Fever
Epilepsy
Diabetes
Kidney Problems
Gastric Problems
Depressive Illness
Serious illness or hospitalised in last 5 years
Do you have any artificial or prosthetic joint?
Have you ever had contact with HIV, Hepatitis B or Hepatitis C?
Have you ever had an unfavourable reaction to local anaesthetic?
Women: Are you pregnant now?
Do you currently smoke?
Do you wish your child/children (aged 13-18) to receive free dental treatment made available under the Ministry of Health Agreement?
Please Note:
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice will require you to undertake a confidential blood test.
I will settle my account with Capital Dental of the day unless prior arrangement has been made. All accounts are liable for interest/debt collection fees for outstanding accounts.

I confirm that the information above is true and correct to the best of my knowledge.
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