Medical Dental Form

Dental Treatment Consent Form during the Covid-19 Pandemic

Do you consent to messages being left on the telephone numbers provided? Yes No If you have answered YES to any of the above please provide details here:

Are you at present taking any medicine or tablets? Yes No

If Yes, please provide details:-

Are you pregnant? Yes No Have you had a baby within the last year? Yes No

In the past 2 years have you undergone any operations? If Yes, please provide details here:-

In the past 2 years have you been treated with Hydro-Cortisone or Corticosteroids? E.g. Prednisolone? Yes No Have you ever had a joint replacement? Yes No Please tick or tell the dentist if you are HIV positive Yes No

What is your average weekly consumption of alcohol? E.g. 1 ½ Pints of 4% beer = 2-3 units / 175ml Glass of Wine = 2-3 units* If you smoke, what is your average number of cigarettes/cigars per week?*

Have you previously been a smoker? Yes No

How long is it since your last visited the dentist? If you are a new patient, who was your previous dentist? Is there a particular issue you would like to address, e.g. Check Up / Toothache / Cosmetic / Bleeding Gums / Other? How did you hear about us? Next of Kin Name: Relationship: Tel No:

Vaccination status:

Double + Booster Vaccincation Single Vaccincation No Vaccincation

I consent to my details being held in accordance with the GDPR practice protocols which can be found on our website www.royalhousedental.co.uk

Yes No

I consent to the practice contacting me via:

Email Text

Patient Signature: