Under 18yrs Old - Dental On Mahoe

First Name

Last Name

Date of Birth:

Home address:

Postcode:

Email address

Home phone:

Parent Mobile:

Childs Mobile

Occupation

Emergency contact person

Phone Number

Family Doctors Name

Phone

Are you Presently receiving any medical Treatment?

Yes

No

Have you any allergies that you are aware of?

Yes

No

Have you ever experienced excessive bleeding form dental treatment, cuts or scratches?

Yes

No

Have you ever experienced excessive bleeding form dental treatment, cuts or scratches?

Yes

No

Have you ever experienced excessive bleeding form dental treatment, cuts or scratches?

Please Provide details:

Have you ever taken long term medications?

Yes

No

If yes please list

Have you any allergies to medicines?

Yes

No

If yes please list

Have you any allergies to medicines?

Yes

No

If yes please list

Do you have any artificial Joints? Eg hip joint

Yes

No

Have you ever had contact with the AIDS virus or Hepatitis B virus?

Yes

No

Have you ever had a reaction to an anaesthetic?

Yes

No

Are you Pregnant now?

Yes

No

if yes, Pregnancy due date

Are there any other aspects concerning your health that you think we should know about?

Yes

No

If yes Please indicate

Are you currently taking any drugs or medicines?

Yes

No

Does your jaw ‘click’ or hurt

Yes

No

Does your jaw ‘click’ or hurt

Yes

No

Do you think you have occasional bad breath

Yes

No

Do you think you have occasional bad breath

Yes

No

Do you Smoke

Yes

No

Additional information:

Signed Patient/Parent/ Guardian

3 + 7 =