If you are attending us for the first time please print out and complete this form and bring it on your first visit.
Personal Details
| Title: | Name: | ||
|---|---|---|---|
| Address: | |||
| Date of Birth: | |
|---|---|
| Telephone (daytime): | |
| Telephone (evening): | |
| E-mail address: |
Business details
| Address: | |
|---|---|
| Postcode: | |
| Telephone (daytime): | |
|---|---|
| E-mail address: | |
| Occupation: |
Dental History
| When was your last dental examination: | |
|---|---|
| How did you hear about us? | |
| Do you have dental insurance? Yes No | |
About You
| Q: Are you happy with your smile? | Yes No |
|---|---|
| Q: Would you like your teeth to look whiter or brighter? | Yes No |
| Q: Are your teeth sensitive? | Yes No |
| Q: Have you any teeth you think are unsightly, misshapen or out of line? | Yes No |
| Q: Are you concerned you may have bad breath or an unpleasant taste in your mouth? | Yes No |
| Q: Do your gums bleed when brushing or flossing? | Yes No |
| Q: Do you suffer from headaches/neck aches or shoulder pain? | Yes No |
| Q: Do you clench or grind your teeth? | Yes No |
| Q: Do you smoke? | Yes No |
| If so, how many a day? | |
| Q: Are you concerned about: | |
| Old crowns that do not do not match your other teeth or have dark lines at the gum? | Yes No |
| Old or stained fillings that show when you smile? | Yes No |
| Silver fillings that you would like replacing with tooth coloured restorations? | Yes No |
| Any missing teeth that you would like to replace? | Yes No |
Are you…
| Q: Fit and healthy? | Yes No |
|---|---|
| Q: Taking pills, medicines or tablets? | Yes No |
| Q: Allergic or have reacted adversely: | |
| Penicillin or any other drug or medicine? | Yes No |
| Latex or other materials? | Yes No |
| Costume jewellery or other metals? | Yes No |
| Q: Taking any of the following: | |
| Antibiotics? | Yes No |
| Anticoagulants? | Yes No |
| Medicine for high blood pressure? | Yes No |
| Cortisone (steroids)? | Yes No |
| Insulin or other medication for diabetes? | Yes No |
| Tablets for Osteoporosis (bisphosphonates)? | Yes No |
| Other? | Yes No |
In the past have you…
| Q: Had any serious illness or operation? | Yes No |
|---|---|
| Q: Had any of the following diseases or problems: | |
| Rheumatic fever or rheumatic heart disease? | Yes No |
| Heart trouble, replacement heart valve, high blood pressur or stroke? | Yes No |
| Sinus trouble? | Yes No |
| Asthma? | Yes No |
| Diabetes? | Yes No |
| Hepatitis or HIV? | Yes No |
| Q: Had abnormal bleeding associated with previous extractions, surgery or trauma? | Yes No |
| Q: Had any problems with previous dental treatment? | Yes No |
Women only
| Q: Is there a possibility that you may be pregnant? | Yes No |
|---|---|
| If so, what is your estimated date of delivery? | |
Final Comments
| Q: Is there anything else you would like to tell us? |
|---|
