Over 18yrs Old Please fill the form below to book an appointment. We will endeavour to contact you as soon as possible Adult Patient Form First Name Last Name Date of Birth: Home address: Postcode: Email address Home phone: Mobile: Work Phone Occupation Emergency contact person Phone Number Medical Doctors Name Phone 1. Are you receiving any medical treatment at the present time? Yes No Details 2. Are You taking any medicines, tablets, capsules or drugs ? If so please list. Yes No Details: 3. Have you experienced any allergies or unusual effects from any tablets, drugs, injections, Anaesthetic or latex? Yes No Details: 4. Have you ever had any of the following? If so please tick as appropriate Rheumatic Fever Heart Surgery High Blood Pressure Stroke Arthritis Hepatitis-Specify type A,B,C Bronchitis or Chest Problems Asthma Epilepsy Anaemia Diabetes Kidney Trouble Gastric Problems Cold Sores Depressive Illness Severe Headaches Have you ever been given or currently taking medication for cancer involving bone? Yes No Have you ever been given or are currently taking the drug Fosamax? Yes No Have you had any prosthetic surgery? (eg heart valve or Hip Replacement) Yes No Details Women: Are you Pregnant? If So, how many months Yes No Are you HIV positive? Yes No Are you at risk of HIV exposure? Yes No Do you Smoke Yes No Are there any other aspects concerning your health that you think we should know about? Yes No Name of last Dentist Approximate date of last dental visit Do you have Dental pain or a Dental Problem at present? Have you ever experienced excessive bleeding or bruising from dental treatment, cuts or scratches? Yes No Do you become anxious or uncomfortable when you are having dental treatment? Yes No How did you hear about us? Sign:Patient to sign here or legal gaurdian or representative Relationship to Patient 6 + 4 =