Medical History Form

To enable us to treat our patients in a safe and appropriate manner, we require our patients or their representatives to fill out a concise medical history form and send it to us, ideally prior to our visit to them to alert our dentists and staff to any potential problems we may come across.  Please fill in the form entirely and as accurately as possible.

The medical history form can be downloaded here(DOCX format). Please right-click on this link and select ‘save link as’ to save a copy of the empty form on your computer.  You can open this form with a document viewer such as Microsoft Word, LibreOffice or Google Docs.

In submitting the medical form to us, you may choose to print it and send it to us in the post or by fax (DOCX format), but the it would be easier if the form is submitted electronically.  A PDF version of the medical history form is available here

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Medical History Form
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The best number for us to reach you on
In case we cannot reach you on the primary number
The GP surgery you are registered with, just in case we need to contact them

You are at higher risk of COVID-19 if you have had the following symptoms: a new continuous cough, a temperature (more than 37.8 C) or a change in the sense of smell or taste; or alternatively, if you or a member of your household/care home have tested positive for COVID-19, or have been told to isolate by the 'track & trace' program, and you/they are still in the isolation period.

We need to screen you and your household/care home for COVID-19

Which of the following conditions do you/have you suffer/ed from? (Please give details)

What Is Your Drug History?

Including illicit or 'off-label' medication
Click or drag files to this area to upload. You can upload up to 3 files.
E.g. scan of a repeat prescription, any Xrays, pictures, etc. Extensions allowed: jpg, png, bmp, pdf, tif, tiff
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Units Per Week
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