To our new patients to Specialist Dental Centre, please fill in the form below

If you have a healthcare summary from GP please bring to Consultation

Please list any medications you may be taking

Please list any known ALLERGIES or ADVERSE REACTIONS to drugs (Especially antibiotic eg. Penicillin), medication, antiseptics, local anaesthetics, preservatives that we should know about.

If you are in any doubt about your medication, please bring a Health Care Summary from your General Practitioner or the bottle or packets to the practice to show your specialist.

Declaration

In submitting this form, I acknowledge that this represents an accurate medical history. I will advise my specialist of any changes to my medical history in the future.
I am happy for reports on my condition to be sent to my referring doctor/dentist.
I am happy for copies to be sent to relevant health professionals involved in my care: Yes/No
I understand that all medical details will be treated with complete professional confidentiality.
I have read the privacy policy overleaf. I understand that my information will be held in the consulting rooms. I am aware of the financial policy of the practice.