Medical Form





    • Attending or receiving treatment from a doctor, hospital or clinic?

    Attending or receiving treatment from a doctor, hospital or clinic?

  • YesNo

  • An expectant or nursing mother?

  • YesNo

  • Taking any medication? e.g. Asprin

  • YesNo

  • Taking any medication for bones?

  • YesNo

  • Receiving blood transfusion services or have you ever had a blood transfusion?

  • YesNo

  • Carrying a medical warning card?

  • YesNo

  • Allergic to medicines, foods, materials? e.g. Penicillin, Latex

  • YesNo

  • Aware of any other illnesses?

  • YesNo

  • Had rheumatic fever?

  • YesNo

  • Had jaundice, liver, kidney disease or hepatitis?

  • YesNo

  • Been told you have a heart murmur, angina, blood pressure, heart attack?

  • YesNo

  • Had a bad reaction to general or local anaesthetics?

  • YesNo

  • Had a joint replacement?

  • YesNo

  • Been Hospitalised? What for and when?

  • YesNo

  • Have arthritis?

  • YesNo

  • Have a pacemaker, artificial valves or have you had any heart surgery?

  • YesNo

  • Have high blood pressure?

  • YesNo

  • Bruise/have prolonged bleeding? e.g. following tooth extraction

  • YesNo

  • Suffer from hayfever, eczema or asthma?

  • YesNo

  • Having fainting attacks, giddiness or epilepsy?

  • YesNo

  • Have diabetes?

  • YesNo

  • Have bronchitis, asthma, COPD?

  • YesNo

  • Smoke cigarettes? If yes, how many/day?

  • YesNo

  • Drink alcohol? If yes, how many units week?
    1 unit – half pint beer / 1 glass of wine

  • YesNo

  • Are you H.I.V positive?

  • YesNo

  • Have you been in contact with someone with COVID-19 in the last 14 days?

  • YesNo

  • Have you had COVID-19?

  • YesNo

  • Do you have COVID-19 at present?

  • YesNo

  • If answered yes to any of the above please give details

  • Iā€™d like to be informed of exclusive offers and other practice informationyes
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Meet Our Highly Qualified Dental Team

Contact Us
Regrettably, our NHS services will end 31st March 2024. The practice has been providing dental care for over 40 years and have come to the difficult decision to cease to offer NHS care. All NHS treatments commenced before 1st April 2024 will be completed by the 31st March 2024. We will not be taking any further NHS appointments from 1st April 2024. If you wish to continue to receive NHS treatment you can find an NHS dentist from the NHS website at www.nhs.uk online or by contacting NHS111. If you wish to discuss your treatment options, please do not hesitate to contact our team on 01202 672138 and they will be more than happy to help you.