Medical History Consent Form

Your Details

Name*

Address

Street Address Address Line 2 City County Postal Code

D.O.B (DD/MM/YYYY)*

Telephone Number (mobile preferred)*

Email Address*

Your GPs Details

GP Name

GP 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/medicines

Do 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 21 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

Please read our Covid-19 consent

Coronation Road Dental Surgery has always taken steps to ensure the protection of patients and staff against all risks of cross infection. We will during the period of Covid be operating using strict guidelines composed by the British Dental Association and the F.G.D.P.

At the time of writing these will impose severe restrictions on the number of patients seen each day and limit the types of treatment we are available to carry out. It is our hope and expectation that non-urgent treatment will begin as soon as possible.

We will be following guidelines in a way that will ensure that the risk of contracting Covid-19 is extremely small. All staff will be logged and checked for symptoms and likewise no care will take place on symptomatic patients . However, due to the very nature of the Covid-19 virus we cannot reduce this risk to zero.

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.

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Coronation Road Dental Surgery Medical History Consent Form

Your Details

Your GPs Details

Please read our Covid-19 consent