New Patients Preffered Title MRMRSMISSMSDRPROF Surname First Name/s Guardian Name (If Under 16) Address Postcode Email Method of recall : LetterEmail Telephone (Home) Telephone (Work) Telephone (Mobile) Date of Birth Occupation When did you last visit a dentist? How did you hear of this practice? Name of your Doctor / GP Do you smoke? YesNo Have you been under the care of a doctor / medical professional lately? If so why? Have you ever had contact with: HIV, Hepatitis A, Hepatitis B, Hepatitis C YesNo Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time? YesNo Have you ever had a reaction/allergies to medicines (e.g anaesthetic, penicillin) or other substances (e.g Latex) Please list Are you taking any pills, tablets, medicines or drugs? Please list with amount taken. Please tick if you have any of the following: Heart Murmur,Rheumatic FeverOpen Heart SurgeryHigh Blood PressureStrokeEpilepsyDiabetesAnaemiaKidney ProblemsGastric ProblemsAsthmaChest or Lung DiseaseDepressive IllnessRadiotherapyHave an artificial or prosthetic jointOther Have you ever had treatment for osteoporosis or taken bisphosphonates e.g Fosamax? YesNo Woman: Are you pregnant? If so how many weeks? I confirm that the information provided is true and correct to the best of my knowledge. Date: Signed:
