Title

Gender Gender Male Female Other

First Name

Surname

Date of Birth

Occupation

Address

Postcode

Telephone

Email Address

Next of Kin

Next of Kin Contact Number

GP's Name

GP's Address

Name of person/s who are authorised by you to request information regarding your dental treatment

Contact relationship to you

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist? Are you attending or receiving treatment from a doctor, hospital, clinic or specialist? Yes No

Please provide details

Pregnant or possibly pregnant? Pregnant or possibly pregnant? Yes No

Please provide details

Please list any prescription medications, non-prescription medicine, herbal treatments or supplements you are taking.

Are you allergic to local anaesthetics? Are you allergic to local anaesthetics? Yes No

Are you allergic to Latex (Gloves, Balloons), Acrylic? Are you allergic to Latex (Gloves, Balloons), Acrylic? Yes No

Are you allergic to foods? Are you allergic to foods? Yes No

Are you allergic to any medicines? Are you allergic to any medicines? Yes No

Are you allergic to any metals? Are you allergic to any metals? Yes No

Are you allergic to any anything else? Are you allergic to any anything else? Yes No

Have you had Jandice or Liver/Kidney Disease ? Have you had Jandice or Liver/Kidney Disease ? Yes No

Have you had Hospital Treatment? Have you had Hospital Treatment? Yes No

Have you had Fainting, Giddiness, Blackouts or Epilepsy * Have you had Fainting, Giddiness, Blackouts or Epilepsy * Yes No

Have you had Blood refused by a blood transfusion centre? Have you had Blood refused by a blood transfusion centre? Yes No

Have you had Arthritis? Have you had Arthritis? Yes No

Diabetes or Family History of Diabetes? Diabetes or Family History of Diabetes? Yes No

Bone or Joint Disease Bone or Joint Disease Yes No

A Pacemaker or Heart Surgery A Pacemaker or Heart Surgery Yes No

Infectious Diseases such as HIV or Hepatitis Infectious Diseases such as HIV or Hepatitis Yes No

Brain Surgery Brain Surgery Yes No

Hay Fever, Eczema or Other Allergy Hay Fever, Eczema or Other Allergy Yes No