Have you ever had or do you have any of the following? (Please tick)
Are you allergic to any medications? List if any:
Please list all medications you are currently taking:
Have you been a patient in the hospital in last 4-5 years? If so, why and when?
Do you have any artificial joints or heart valves? If so, what and when did you have?
Do you have any heart conditions? If so, what?
Do you have any other disease or condition not mention on this form?
Do you smoke? (If so, how many per day?)
Has anyone ever told you that you snore? After 7 hours of sleep, do you feel refreshed?
Are you pregnant? If so, how many weeks? Nursing?
GP's Name and location:
Consent for treatment
1. I hereby authorise the dentist or designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.
2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by myself and to employ such assistance as required to proper care.
3. I agree to the use of anaesthetics and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.
5. I authorise that this data may be reviewed by team members of the dental practice.