Confidential Medical History Form

Medications, medical conditions and allergies can affect dental treatment. So, to obtain the best and safest care, our dentist needs to know of any problems which may affect your treatment.

Please ensure that you answer ALL questions on this form and all contact details are filled out correctly. Thank you.

If you prefer, we also have a printable version of this form.


Are you

(If you select ‘Yes’, please provide details.)



Do you suffer from

(If you select ‘Yes’, please provide details.)



Have you ever had

(If you select ‘Yes’, please provide details.)



Women Only

(If you select ‘Yes’, please provide details.)



Alcohol and smoking

(If you select ‘Yes’, please provide details.)



List Of Prescribed Medications.