Patient Registration

Completed by:
SelfParentGuardian

Title
MrMrsMissMs

Name

Date Of Birth (DD/MM/YYYY)

Address

Post Code

Telephone Number (optional)

Mobile Number (optional)

Email address

Occupation (optional)

Do you have dental insurance?
YesNo

Do you smoke?
YesNo

Units of alcohol per week.
1 unit equals to 25ml single measure of whisky, or a third of a pint of beer, or half a standard (175ml) glass of red wine.

If you completing this form for a child, please enter his/her school (optional):

If you completing this form for a child, please enter his/her Social Security Number (optional):

Doctor's Name and Address

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
YesNo

Have you ever been told you have a heart problem, Angina, raised blood pressure, heart attack or heart murmur?
YesNo

Do you have a pacemaker, or have you had any form of heart surgery?
YesNo

Do you have diabetes?
YesNo

Have you had jaundice, hepatitis or any other liver or kidney disease?
YesNo

Do you bruise easily or have you suffered from excessive bruising following an injury or any form of surgery or tooth extraction?
YesNo

Have you suffered any complications during or after a tooth extraction; e.g. difficult extraction, infection?
YesNo

Do you have fainting attacks, giddiness, blackouts or epilepsy? *
YesNo

Do you suffer from any allergies to medicines, food or materials?
YesNo

Have you had a bad reaction to a general or local anaesthetic?
YesNo

Are you pregnant?
YesNo

Are you taking or have you taken steroids in the last 2 years?
YesNo

Are there any other aspects concerning your health that you think the dentist should know about?
YesNo

Are you taking any medicines prescribed by your doctor or of your own accord?
YesNo

Do you have any infectious diseases (e.g. TB, HIV or Hepatitis)?
YesNo