Consent & Medical History Form

1Consent Form

2Medical History Details

Patient's Details
Patient's Name Requiring Visit*
Name of Care Home (if applicable)*
Address of Patient
Street Address Address Line 2 City Postcode
Patient's Date of Birth*
Reason for Dental Visit eg new dentures, examination etc
Payment

Please ensure you complete the medical history part of the form for each patient.

Please note, we require payment before we are able to arrange an appointment. Please check our latest prices here...

You can make payment by card over the phone, by cheque payable to Leeds Dental Team Ltd, or you can make a bank transfer to:
Leeds Dental Ltd
Sort Code: 53-61-07
Account Number: 70394288

Please remember to quote the name of the patient the payment is related to as a pay reference. If further treatment is required, you will be given a quote, and payment will be required at the next visit.
Consent
Full name of person giving consent for dental visit/treatment eg power of attorney*
Contact Telephone Number*
Billing Address*
Street Address Address Line 2 City Postcode
I, named above, give full consent for Mr G Temple to examine and provide dental treatment
Signature
Relationship to Patient*
Date of Form Completion
MM slash DD slash YYYY
Please click Next below to continue to the Medical History Form

Medical History Details
1. Is the patient currently receiving treatment from a doctor, hospital or clinic?*
2. Please name all medications the patient is taking, or ointments they are using*
3. Is the patient currently taking any self prescribed medicines?*
4. Does the patient have any allergies to any medicines or materials? Eg penicillin or latex*
5. Does the patient carry a medical warning card?*
6. Does the patient suffer from hay fever or eczema?*
7. Does the patient suffer from arthiritis or osteoporosis?*
8. Has the patient ever had a heart attack or a pacemaker fitted?*
9. Does the patient suffer from heart problems, blood pressure, or has ever had a stroke?*
10. Is the patient diabetic? Or anyone in their family?*
11. Does the patient suffer from persistent bleeding following injury, tooth extraction or surgery?*
12. Has the patient ever had Rheumatic Fever, Chorea or Endocartitis?*
13. Does the patient suffer from Bronchitis, Asthma or any other chest problems?*
14. Does the patient have, or has had, any form of cancer?*
15. Has the patient ever taken Biphosphonates?*
16. Please give details of your doctor. Name, Practice, Address and Phone*
17. Does the patient suffer from cold sores?*
18. Has the patient ever had liver diseases eg jaundice or hepatitis?*
19. Does the patient suffer from fainting attacks, giddiness, blackouts or epilepsy?*
20. Has the patient ever had a bad reaction to a local or general anaesthetic?*
21. Has the patient ever had a joint replacement or other implant?*
22. Has the patient ever had treatment that required a stay in hospital?*
23. Has the patient ever received growth hormone treatment before the 1980's?*
24. Has the patient ever had brain surgery?*
25. Does the patient regularly drink more than 14 units of alcohol per week?*
26. Does or did the patient smoke/chew any tobacco products or use Guthka or Supari?*
27. How many fizzy drinks does the patient drink in a week?*
28. Is the patient currently pregnant or have they had a baby in the last 12 months?*
29. Does the patient suffer from any infectious diseases eg HIV/Hepatitis?*
30. Has the patient ever had blood refused by the blood transfusion service?*
31. Does the patient have any other serious illness that you have not disclosed above?*

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Consent & Medical History Form

Patient's Details

Payment

Consent

Medical History Details

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