Confidential Patient Questionnaire

By submitting this form, you confirm that the information provided is true and correct to the best of your knowledge.

How did you hear about us?
Name
Address(Required)
MM slash DD slash YYYY
Name, Address, & Phone Number

Dental Concerns

Please tick if you have any concerns about

Medical History

Please check that the following information is correct, adding in all the necessary information.
Heart(Required)
Do you have or have you had any of the following conditions? (tick all that apply)
Blood(Required)
Do you have or have you had any of the following conditions? (tick all that apply)
Other(Required)
Do you have or have you had any of the following conditions? (tick all that apply)
Allergies(Required)
Do you have or have you had any of the following conditions? (tick all that apply)
Warnings(Required)
Do you have or have you had any of the following conditions? (tick all that apply)
Alternatively, you can upload a photo of your medications below.
Max. file size: 128 MB.

Declaration

Health & Safety(Required)
Although rare, accidental injury to your dentist and staff can occur during the handling of sharp used instruments. If this happens during the course of your treatment, our practice requires both the patient and staff member to undertake a blood test. Do you agree to a confidential blood test if required?
Medical(Required)
I confirm that the above medical history is a true and accurate record. I understand that this information helps to ensure patient safety during treatment.
Late Cancellations/Missed Appointments(Required)
I Understand failure to attend an appointment, late attendance or cancellation within 48 hours may incur cancellation fees.
Payments(Required)
I understand that payment is required at the time of treatment/consultation. Unpaid accounts may incur administration and third party collection fees.