Medical History Consent Form Coronation Road Dental Surgery Medical History Consent Form Your DetailsName*Address Street Address Address Line 2 City County Postal Code D.O.B (DD/MM/YYYY)*Telephone Number (mobile preferred)*Email Address* NHS Number*Your GPs DetailsGP NameGP Address Street Address Address Line 2 City County / State / Region Postal Code Are you currently receiving any medical care or drugs from your doctor/hospital?* Yes No Please list any medical care or drugs prescribed.Are you carrying a medical warning card?* Yes No Do you suffer from allergies to any drugs/medicines?* Yes No Please list allergies to any drugs/medicinesDo you suffer from allergies to any foods or latex?* Yes No Please list any allergies to any foods or latex.Do you suffer from hayfever or eczema?* Yes No Please provide additional information.Do you suffer from bronchitis, asthma or any other respiratory disease?* Yes No Please provide additional information on any respiratory diseases.Do you suffer from fainting attacks, giddiness, blackouts, epilepsy?* Yes No Please provide further information.Do you suffer from heart or blood pressure problems?* Yes No Please provide further information.Are you a diabetic?* Yes No Do you suffer from arthritis, bruising or persistent bleeding from extractions?* Yes No Please provide further information.Have you ever had rheumatic fever?* Yes No Have you ever had liver disease?* Yes No Have you ever had a bad reaction to general or local anaesthetic?* Yes No Have you ever had a joint replacement?* Yes No Do you regularly drink more than 14 units of alcohol per week?* Yes No Please provide further information.Do you self prescribe any medication?* Yes No Please provide information on any medication self prescribed.Is there any possibility that you may be pregnant?* Yes No Do you smoke any tobacco products now (or did you in the past)?* Yes No Communication Consent FormWe process personal data for the purposes of providing optimum dental healthcare, sending important updates to you, providing you with news about treatments and what is happening at the practice and informing you about our services. You can withdraw your consents at any time.The practice can contact me about my treatment:* By email By text No thank you I would like to receive details of new treatments and services at the practice:* Yes by email Yes by post No thank you Your personal information is never passed to third parties for their own marketing, sales or promotions. We have strict arrangements with companies who process your data on our behalf. For further details about how we process your personal information and your data rights please see our Privacy Notice or contact office@coronationroaddentalsurgery.co.uk or call 0117 966 3697 to request a copy of it. Date of medical history consent declaration* Day Month Year Signature*I understand these risks and am prepared to accept them and proceed with my appointment.Signature*I understand that in order to care for my oral health, Coronation Road Dental Surgery may have to share personal data under the terms and conditions of current GDPR.CAPTCHA
