028 44 830111
This provides the Dentist with important information required for your Dental Treatment and Oral Health Care. All information provided will be kept strictly confidential by the people caring for you.
Please ensure you have your Heath & Care Number before beginning this form - it is required. You can obtain this from your GP or from your Medical Card.
Are you receiving any medical treatment at the present time?
Have you been a patient in hospital during the past two years?
Have you taken any medicine tablets, capsules, or drugs during the past two years?
Have you experienced any allergies or unusual effects from any tablets drugs injections or anaesthetic?
Are you, or have you been, under the care of a doctor during the past two years?
Have you ever had any of the following? If yes, please tick as appropriate.
Have you had any prosthetic surgery? (Heart Valve/Hip Replacement)
Are you taking or have you taken any Bisphosphonates (Osteoporosis)
Are you HIV positive? (if yes please give dentist details)
Are you at risk of HIV exposure? (if yes please give dentist details)
Have you CJD or VCJD? (if yes please give dentist details)
Are you at risk of CJD or VCJD? (if yes please give dentist details)
Do you smoke?
Do you have dental pain /dental problems at present?
Have you ever experienced excessive bleeding or bruising from dental treatment, cuts, or scratches?
Do you become anxious or uncomfortable when you are having dental treatment?
Thank you for submitting and look forward to seeing you at the practice