Medical History Form

If different from postal address
Person to contact in the time of an emergency
If Yes please enter details
Person/Third Party responsible for your fee payment

Medical History

In order to render dental treatment of a high standard, it is necessary to have the following information (which will be handled confidentially). Please help us protect your health and well being...

e.g. Penicillin, aspirin or disinfectants
If Yes please enter details
If Yes please enter details
If Yes please enter details
Tick any that apply
Including over the counter medicines
If Yes please enter details
If Yes please enter details
If Yes please enter details

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