Due to Covid-19 requirements, please fill in the following forms prior to attending an appointment at the practice. If you have any questions please get in touch. Thank you.

    Consent to dental treatment during COVID-19

    I, , knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

    I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

    All dental procedures create water spray(aerosol) which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

    • I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental practice.

     

    Confidential Medical History Form


    Personal details
    Title
    First Name
    Surname
    Your Address

    Postcode
    Date of Birth
    Gender
    Occupation
    Tel No
    Mobile
    Email Address

    When did you last receive dental treatment?
    Your G.P Name and Address

    Next of Kin Details
    Name and Contact Number

    Relationship to you

     

    Have you tested positive for COVID-19 recently?
    YesNo

    Do you currently have a raised temperature or fever? (Feel hot to touch on your chest/back)
    YesNo

    Do you currently have any of the following: partial/total loss of your sense of smell or taste, a sore throat, runny nose, cough, cold or flu?
    YesNo

    Have you had any COVID19 vaccinations?
    YesNo

    Are you currently attending or receiving treatment from a doctor, hospital or specialist?
    YesNo

    Are you pregnant or a nursing mother?
    YesNo

    Are you currently taking any prescribed medicines, tablets, drugs or injections or using any creams, ointments or inhalers?
    YesNo

    Are you carrying a medical warning card?
    YesNo

    Do you suffer from allergies to any medicines, food, substances or materials? (e.g. Penicillin, Latex/Rubber)
    YesNo

    Do you suffer from hay fever or eczema?
    YesNo

    Do you suffer from asthma, bronchitis or other chest conditions?
    YesNo

    Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
    YesNo

    Do you suffer from heart problems, angina, blood pressure problems or stroke?
    YesNo

    Are you a diabetic (or is anyone in your family)?
    YesNo

    Do you suffer from arthritis?
    YesNo

    Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?
    YesNo

    Do you suffer from any infectious diseases, including HIV and hepatitis?
    YesNo

    Are you HIV positive?
    YesNo

    Have you ever had rheumatic fever or chorea?
    YesNo

    Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease?
    YesNo

    Have you ever had any other serious illness?
    YesNo

    Have you ever had your blood refused by the Blood Transfusion Service?
    YesNo

    Have you ever had a bad reaction to local or general anaesthetic?
    YesNo

    Have you ever had a joint replacement or other implant?
    YesNo

    Have you ever had treatment that required you to be in hospital?
    YesNo

    Have you ever had heart surgery or do you have a pace maker?
    YesNo

    Have you ever had brain surgery?
    YesNo

    Did you receive growth hormone treatment before the mid 1980’s?
    YesNo

    Do you have any close relatives with Creutzfeldt Jakob Disease?
    YesNo

    Are you taking or have you ever taken Alendronic Acid or Bisphosphonates?
    YesNo

    Do you consume any alcohol? (If so, how many units do you consume per week?)
    YesNo

    Do you smoke any cigarettes? (if so, how many per day)
    YesNo

    Do you smoke or chew any tobacco products, pan, use gutka or supari?
    YesNo

    Is there any other information which your dentist might need to know about, such as self-prescribed medications? (i.e. Aspirin)
    YesNo

     

    Consent
    DentalHouse will never give your information to a third party for marketing purposes. We will only share relevant information from your dental records with other professionals when clinically required, for example when we need to refer you to hospital or specialist services.

    To indicate consent please enter the following details:
    Name
    Status

     

    You must fill in all fields AND tick BOTH consent boxes (one above and one at the top of this form) to be able to send these forms.

    If you are having any difficulties completing this form please get in touch.