If you currently have a cold sore then dental treatment needs to be postponed until after this has healed: please call us now and we will be happy to reschedule your appointment.

Your Name (required)

Date of Birth (required)

First line of your address

Postcode

Your Email

Your Doctor's name, or the name of your GP surgery

Your Occupation

Are you taking any medicines or tablets from your doctor? YesNo Full list of medication:
Are you taking any steroids or have done in the last 2 years? YesNo

Are you allergic to any food, medicine or materialsYesNo
Are you likely to be pregnant?YesNo

Please list the medical conditions and provide details if you have ticked yes to any of the above.

Have you ever had jaundice, liver or kidney disease or hepatitis? YesNo
Have you ever had rheumatic fever, heart or valve surgery, endocarditis, a heart attack, angina or other heart problems? YesNo
Do you have high or low blood pressure? YesNo
Have you ever had a bad reaction to local or general anaesthetic? YesNo
Have you ever had a stroke? YesNo
Have you recently had a major operation or hospital treatment? YesNo
Have you ever had a positive test for V CJD or for HIV? YesNo

Please list the medical conditions and provide details if you have ticked yes to any of the above.

Do you have a pacemaker? YesNo
Do you suffer from bronchitis or asthma? YesNo
Do you suffer from excessive bleeding or bruising? YesNo
Do you suffer from epilepsy, fainting attacks or vertigo? YesNo
Do you have Diabetes (please write type in the details box below)? YesNo
Do you carry a warning card? YesNo
How many cigarettes do you smoke per day?
How many units of alcohol do you drink per week?

Please list the medical conditions if you have ticked yes to any of the above, please also include any other medical diagnoses and conditions not listed here, and any other aspects of your health that we should know about.

Our chairs have a weight safety limit of 22 stones. If you think you may be above this limit then please call the surgery now on 01904764539 so that we can plan your care safely.