South Coast Dental Centre - Appointment booking

Patient Details

First and Last Name

Date of Birth

Address in full

Home telephone

Mobile (for sms updates)

Email Address

Questions

Tick the boxes and give details if your answer is 'YES'
If your answer is 'NO' leave blank.

Are you currently receiving treatment from a doctor, hospital or clinic? Please provide details

Are you currently taking any prescribed medicines? Which ones?

Are you carrying a medical warning card? Which one?

Do you suffer from allergies to any medicines (e.g penicillin), substances (e.g latex/rubber) or foods? Please provide details

Do you suffer from hay fever or eczema? Please provide details

Do you suffer from bronchitis, asthma or other chest conditions? Please provide details

Do you suffer from fainting attacks, giddiness, blackouts or epilepsy? Please provide details

Do you suffer from heart problems, angina, blood pressure problems, or stroke? Please provide details

Are you diabetic (or is anyone in your family?) Please provide details

Do you suffer from arthritis? Please provide details

Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? Please provide details

Do you suffer from any infectious diseases (including HIV and hepatitis)? Please provide details

Have you ever had rheumatic fever or chorea? Please let us know which:

Have you ever had liver disease (e.g jaundice, hepatitis) or kidney disease? Please provide details

Have ever had any other serious illness? Please provide details

Have you ever had blood refused by the Blood Transfusion Service? Please provide details

Have you ever had a bad reaction to general or local anaesthetic? Please let us know which

Have you ever had a joint replacement or other implant? Please provide details

Have you ever had treatment that required you to be in hospital? Please provide details

Have you ever had heart surgery? Please provide details

Have you ever had brain surgery? Please provide details

Did you ever receive growth hormone treatment before the mid 1980's? Do you remember which?

Did you have any close relatives (parent, sibling, child, grandparent or grandchild) with Creutzfeldt Jakob Disease (CJD)? Please let us know who

Did you regularly drink more than 14 units of alcohol per week? How many units?

Do you smoke any tobacco products now (or did you in the past)? Please provide details

Do you chew tobacco, pan, use gutkha or supari now (or did you in the past)? Please let us know which

Is there any other information (such as self-prescribed medicines (e.g asprin)? Write here

Appointment Booking

Patient Details

Questions

Tick the boxes and give details if your answer is 'YES'
If your answer is 'NO' leave blank.

Patient Record Form

When you arrive for your appointment, you will be asked to sign your patient record form. Here is an example.

Please press SUBMIT below,

Appointment Booking

Patient Details

Questions

Tick the boxes and give details if your answer is 'YES'If your answer is 'NO' leave blank.

Patient Record Form

When you arrive for your appointment, you will be asked to sign your patient record form. Here is an example.

Please press SUBMIT below,

Tick the boxes and give details if your answer is 'YES'
If your answer is 'NO' leave blank.