Patient Registration

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Patient Registration

Please complete your medical history below. The completed form will be emailled to our reception team and ready for you to review at your appointment.

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Personal Details

Medical Details

Do you normally require antibiotic cover before dental treatment?*
Have you had any abnormal reactions to local or general anaesthesia?*
Do you smoke?*
Females, are you currently pregnant?
Are you being treated by a doctor at present?*
Are you taking any medication at present?*
Do you have any allergies?*

Do you have now, or have you ever had, any of the following medical conditions?

Diabetes*
Asthma*
Rheumatic fever*
Tuberculosis*
Steroid Therapy*
Stomach or digestive condition*
Bronchitis, emphysema or other lung diseases*
Anxiety, depression and other mental health conditions*
High blood pressure*
Heart disease or heart complaints*
Stroke*
Excessive bleeding*
Kidney disease*
Hepatitis or other liver diseases*
Epilepsy*
Prosthetic implant*
Cardiac pacemaker*
Treatment for cancer*
Radiation therapy*
Thyroid disease*
Contact with blood borne viruses, e.g. HIV/AIDS*
Anaemia, leukaemia or other blood disorders*
Bone disease, including osteoporosis*
Sleep aponea*
I consent to the storage of the above information about my health, documentation by Chermside Family Dental relevant to my general health and dental health, including notes, radiographs, clinical photos and digital images or models, and I consent to the transmission of this information when necessary to another practitioner involved in my care, whether the information is transmitted by post, fax, email or digital transmission.