Home of Dentistry without Anxiety, Fear or Pain

Evenings and Saturday Appointments Available

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  • Call Us ON: 01923 824 230
  • Emergency: 07943 361 185

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Confidential Medical / Dental History & General consent form

To help your Dental team provide the best and safest care, please complete the following questionnaire.

  • Date Format: DD slash MM slash YYYY
  • Contact Permission: From time to time we may contact you with details of dental services we provide and various offers or promotions. Please circle YES if you would like to stay updated or NO if you do not wish to be updated with the details of dental services, offers or promotions.

  • HAVE YOU EVER SUFFERED FROM

  • Any Heart Problems
    Heart surgery, Angina, Heart attack, Pacemaker,Stroke, High or low blood pressure, any other heart conditions.
  • Any Chest Problems
    Asthma, Bronchitis, anyother chest conditions.
  • Do you smoke? If ‘YES’, how many?
    If No, have you smoked in the past? How long ago and how many?
  • Are you pregnant?
  • Diabetes
    If yes, how is it controlled:diet, tablets, insulin
  • Epilepsy, fainting attacks, giddiness or blackouts
  • Hiatus hernia or any stomach problems
  • Jaundice, Liver or Kidney disease
  • Hepatitis or HIVor any other blood disorders
  • Easy bruising, prolonged bleeding following injury, tooth extraction or surgery
  • Osteoporosis
    If yes, do you take Bisphosphonates ( tablets or injections) and for how long have you been on them
  • Arthritis

  • HAVE YOU

  • Had a joint replacement
  • Rheumatic Fever
  • Bad reaction to a Local or General anaesthetic
  • Taken Steroids -now or in the past 2 years

  • DO YOU

  • Take any anticoagulants (Eg: Warfarin or any other blood thinning medications)
  • Carry a warning card or an Epipen
  • Have allergies to any medications /materials?Antibiotics/latex
  • Take any Medications:
    Please list all medications including over the counter / herbal / homeopathic.

  • PAST DENTAL HISTORY

  • Have you experienced any discomfort from your teeth recently?
  • Are your teeth sensitive to hot or cold?
  • Are you aware of clenching or grinding your teeth?
  • Do your jaw joints ever hurt or click?
  • Do your gums bleed easily or feel tender?
  • Are you troubled with bad breath or a bad taste?
  • Anything else you would like to mention?
  • Are you happy with the state of your teeth and smile?

  • WE PROVIDE TEETH WHITENING, TEETH STRAIGHTENING & NON-INVASIVE COSMETIC SMILE IMPROVEMENT

  • If Yes, please describe your expectations in a few words:
  • I consent to proceed with the dental care at Dene Dental Practice.
  • Date Format: DD slash MM slash YYYY

  • Patients’ Consent for clinical photography (taking, storing and using Dental images/ videos) on digital media or printed publications of Dene Dental Practice

  • I give permission to Dene Dental Practice to take, store and use my Dental images/ videos ( of face / teeth / smile ) either in printed publications ( adverts / newsletters / display / leaflets ) or digital media ( website/ social networks) for educational or promotional purposes. Patients’ personal data and identity will be protected and their names, age, DOB will not be published along side the dental images / videos.
  • Date Format: MM slash DD slash YYYY

  • Privacy Statement

  • At Dene Dental Practice we take your privacy seriously.

    We pride ourselves on our high standards, and can assure you that our data practices are fully compliant with GDPR. Your details are stored securely, and we do not pass your details onto other parties for unsolicited marketing purposes.

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