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Dental

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Have you had any operations or been admitted to hospital in the last 12 months? yes No
Are you taking any other medications? yes No
What is your blood pressure?
What is your height?
Height?
What is your weight?
Weight?
Do you smoke? yes No
Do you drink alcohol? yes No
Do you suffer from any allergies? yes No
Is there any medical conditions that run in your family? (e.g, Diabetes, Hypertension, Coronary heart disease) yes No
If you are female, are you pregnant, planning to get pregnant or breast feeding? yes No
Do you suffer from depression, anxiety or any other mental heath issues? yes No
Are you currently suffering from a dental infection? yes No
Have you seen or contacted a dentist regarding this infection? yes No
Do you agree not to drink alcohol when taking this type of medication?
More Information
Would you give us permission to contact your GP if we need to discuss your treatment and to keep them informed about any medication we may prescribe to you? yes no
I have read and agree to the Terms and Conditions and privacy policy.

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