Medical History form | The Dentist, Implants, Veneers, Emergency Center in Birmingham

About you

Title

First name*

Surname*

Gender

Date of birth*

Email*

Daytime phone

Mobile

Address

Town

Postcode*

Occupation

Last dental visit

Any additional notes

GP & preferences

Doctor’s name and address

Doctor’s telephone

Marketing preferences (optional)

Post Email Telephone Text

Next of kin

Title

First name

Surname

Relationship

Contact address

Contact no.

I consent to you contacting my next of kin in a medical emergency

Lifestyle & consent

Alcohol units per week

Typical drinking pattern (optional)

Do you smoke tobacco now (or did you in the past)? Yes No In the past

Times per day

Do you chew tobacco/paan/gutkha/supari now (or did you in the past)? Yes No In the past

Times per day

Self-prescribed medicines (e.g. aspirin)

Declaration

I confirm the information is accurate to the best of my knowledge and consent to you storing and using it for my dental care.

Completed by Signature (type your full name)*

Date: