Medical History Form - Dental Implant Centre

Patient Registration & Medical History

"*" indicates required fields

1Patient Registration

2COVID-19

3Dental Questions

4Medical History Form

5Office use only

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Date

MM slash DD slash YYYY

Name*

Prefix First Last

Date of Birth*

Day

Month

Year

Sex*

Male

Female

Contact Details

Address

Street Address Address Line 2 City County Postcode Country

Home Phone Number

Mobile Number

Enter Email Confirm Email

Newsletter

Yes, Sign me up to receive health tips, special offers and much more.

Occupation

Please select

Occupation other

Ethnicity*

Please select your ethnicity

Date of last dental visit

DD slash MM slash YYYY

When did you last have a dental visit

Where did you learn about the practice?

Leaflet/Advert

Passing by

Internet

Recommended by friend/family member ?

Other

Their name/relationship to you

Would you like us to see any of your friends or family also:

Yes

Name(s):

Name

Phone Number

Would you like to be seen within the NHS (may be a waiting list) or PRIVATE outside of the nhs (earlier availability, finest materials, cosmetic treatments etc?

PRIVATE

NHS (Excludes cosmetic treatments)

COVID-19

Do you or anyone in your household have COVID-19?*

Yes

Do you have a new, continuous cough?*

Yes

Do you have a high temperature (37.8 degrees or over)?*

Yes

Do you have a loss of, or change in, your normal sense of taste or smell?*

Yes

Does anyone in your household have a new, continuous cough, or a high temperature, or a loss of, or change in, their normal sense of taste of smell?*

Yes

If you or anyone in your household has, or has had, possible or confirmed COVID - 19, are you still in the self/household isolation period?*

Yes

IF YOU HAVE RESPONDED POSITIVELY TO ANY OF THESE SYMPTOMS WE WOULD STRONGLY ADVISE SELF ISOLATING AND DELAYING NON-ESSENTIAL CARE FOR AT LEAST ONE MONTH. IF YOU HAVE A DENTAL EMERGENCY PLEASE CONTACT THE PRACTICE ON INFO@dentalimplantcentre.com SO THAT WE MAY MAKE SPECIAL ARRANGEMENTS FOR YOUR EMERGENCY CARE.

Consent - COVID-19*

Please tick to confirm the information is correct & Sign below

Signature - COVID-19*

Date of Signature

What dental treatment(s) are you interested in

New Patient Examination

Dental Implants

Replace All Teeth

Replace Loose Dentures

Braces

Smile Makeover

Teeth Whitening

Hygienist

Pain/Emergency

Facial Aesthetics

Other

I wish to register as a patient with a dentist at Dental Implant Centres @ Twyford Dental

I understand and agree the following

That the agreement by which I will be given dental treatment is an arrangement between the dentist and myself.
That, under my treatment plan, my treatment will have to be paid for in total by the last visit.
That, under my treatment plan; I may be required to pay in advance for certain items of treatment.
That, under my treatment plan, I may be charged a fee of £10 for each 10 minutes of an appointment missed or cancelled without 48 hours prior notice.

Signature

Date

DD slash MM slash YYYY

Doctors surgery

Doctors name

Prefix First Last

Doctors Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Are you

Receiving treatment from a doctor, hospital, clinic or a specialist?

Yes

If Yes, give information

Taking any medicines or tablets (creams, ointments, injections)?

Yes

If Yes, give information

Taking or have taken steroids in the last two years?

Yes

If Yes, give information

Have You

Had rheumatic fever or chorea?

Yes

If Yes, give information

Had jaundice, liver disease or hepatitis?

Yes

If Yes, give information

Ever been told you have a heart murmur or heart problems, angina or heart attack?

Yes

If Yes, give information

High or Low Blood Pressure? If yes, do you know what it is? Date last taken?

Yes

If Yes, give information

Had any blood tests? If so what for?

Yes

If Yes, give information

Ever had your blood refused by the blood transfusion service?

Yes

If Yes, give information

Ever had a reaction to a general or local anesthetic?

Yes

If Yes, give information

Had a joint replacement?

Yes

If Yes, give information

Been hospitalized? If so what for?

Yes

If Yes, give information

Do you

Have arthritis or joint problems / osteoporosis?

Yes

If Yes, give information

Have a pacemaker, or have you had any heart surgery?

Yes

If Yes, give information

Suffer from hayfever, eczema or any other allergy?

Yes

If Yes, give information

Suffer from bronchitis, asthma or any chest conditions?

Yes

If Yes, give information

Have fainting attacks, blackouts or epilepsy?

Yes

If Yes, give information

Have diabetes or does any one in your family?

Yes

If Yes, give information

Have any bleeding disorders?

Yes

If Yes, give information

Carry a warning card?

Yes

If Yes, give information

Ever get cold sores?

Yes

If Yes, give information

Ever Smoke?

Yes

If Yes:

Current

Ex- Smoker

How many a day?

Drink Alcohol?

Yes

How many units a week? (1 unit = ½ pint beer, 1 glass wine, 1 measure of spirit)

Take any of the following medicines below?

Antibiotics

Yes

Diuretics

Yes

Antidepressants

Yes

Insulin

Yes

Anticoagulants

Yes

INR?

E.g. Warfarin

Steroids

Yes

Antihistamines

Yes

Hormones

Yes

Blood pressure Tablets

Yes

Tranquillizers

Yes

Aspirin

Yes

Bisphosphonates

Yes

eg. Fosomax

Any other medicines/Further information?

Females Only

Are you pregnant?

Yes

Do you take oral contraceptives

Yes

Have you had a hysterectomy

Yes

Are you past the menopause

Yes

Any other aspect of your health your dentist should know about?

I consent to my General Medical Practitioner to be contacted for further medical information if and when required
I have disclosed all relevant medical conditions

Signature

Date

DD slash MM slash YYYY

Completed by:

Self

Parent

Guardian

Other

Signature

Please return back to a member of staff. Thank you

Office use only

Signature

Dentist Name

First Last

Date

DD slash MM slash YYYY

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Treatments
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Meet The Team
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Why Us
Referrals

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Patient Stories
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01182 144 040
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Patient Stories
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Implant Diploma Courses

Get in Touch

Dental courses

Treatments
Pricing
Meet The Team
Locations
Why Us
Referrals

Treatments
Pricing
Meet The Team
Locations
Why Us
Referrals

01182 144 040
Treatments
Pricing
Locations
Our Centre
Patient Stories
- Dental Implant Cases
- Patient Videos
Contact Us
Implant Diploma Courses

01182 144 040
Treatments
Pricing
Locations
Our Centre
Patient Stories
- Dental Implant Cases
- Patient Videos
Contact Us
Implant Diploma Courses

Get in Touch

Dental courses

Patient Registration & Medical History

Contact Details

COVID-19

Doctors surgery

Are you

Have You

Do you

Take any of the following medicines below?

Females Only

Please return back to a member of staff. Thank you

Office use only

Treatment Options

Implant Courses

Dental Implant Centre

01182144040

Opening hours:

MON	8:30AM – 5:30PM
TUE	8:30AM – 5:30PM
WED	8:30AM – 5:30PM
THUR	8:30AM – 5:30PM
FRI	8:30AM – 3:30PM