(please copy & paste into a word doc)

NAME:

ADDRESS:

Tel:  Home:                                                   

Business/Work:                    

Mobile:

Date of Birth:

Email address:

Marital Status:

Occupation:

How would you like to be addressed when visiting Gentle Dental?

How did you hear about Gentle Dental?

Who should we contact in the unlikely event of an emergency?

[Name and telephone number]

What are your aims and expectations from your Gentle Dental experience?

Do you have any concerns about visiting the dentist?

Any additional information you feel we should be aware of?

Please tick your preference

• Private
• Plan

Medical details

Name of GP [address & telephone number]:

Please list any medication you are taking and the reason for taking them:

Is there anything that you can’t take or are allergic to?

Please list any serious contagious diseases you have or think you may have?

Please tick and provide details if you have any of the following…

Heart condition

Breathing difficulty

Bleeding problem

Fits or seizures

Diabetes

Liver or kidney disease

Impaired hearing, sight or speech

A pacemaker

Please let us know if you are or think you may be pregnant.

Do you smoke?

How many units of alcohol do you drink per week?

Please let us know if there is anything else which may influence the treatment we can provide for you.

Sign & Date ……………………