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 Name GP Address Street Address Address Line 2 City State / Province / 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 Please read our Covid-19 consentCoronation 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. 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
