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    • Hygienist
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Medical Questionnaire

Medical Questionnaire Form

1 Medical Questionnaire
2 Dental Questionnaire
3 Covid-19 Questionnaire
  • Date Format: DD slash MM slash YYYY
  • General Medical Practioner Details

  • Medical History

  • Medication Strength Dose  
         
    • Edit
    • Delete
    There are no Entries.

    Maximum number of entries reached.

    Please list any medications you are currently taking.
  • Family History

  • Dental Specific Medical

  • Social History

  • Eg. Pint of lager is 3 units and standard glass of wine
  • Please include e-cigarettes and vaping
  • Dental History

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Personal History

  • Gum and Bone Health

  • Tooth Structure

  • Covid-19 Pre-Appointment Screening

    In keeping with the guidance from the UK government and the NHS governing bodies, we are required to complete a Covid-19 screen for all patients attending for a dental appointment. For the safety of patients and our dental team, it is important that we follow the recommended guidelines to stop the spread of the virus. Thank you for your understanding.
    - You receive your Covid-19 test results and are either negative or completely recovered.
    - The risk of Covid-19 has reduced so as not to pose a risk to yourself.
  • If you have had Covid-19 testing please supply date and result:

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • If you have answered yes to any of the above questions we may be required to delay your dental appointment until
    - After a 14 day period of self-isolation has been completed and you are asymptomatic.
    - You receive your Covid-19 test results and are either negative or completely recovered.
    - The risk of Covid-19 has reduced so as not to pose a risk to yourself.
  • Home
  • COVID-19
  • About us
  • Treatments
    • Cosmetic
    • Fillings/Root Canal/Extractions
    • Hygienist
    • Mouth Guards
  • Opening Times
  • Fees
  • Emergencies
  • Feedback
  • Updates & Policies
    • News and Updates
    • Policies
    • Medical Questionnaire
  • Contact
Menu
  • Home
  • COVID-19
  • About us
  • Treatments
    • Cosmetic
    • Fillings/Root Canal/Extractions
    • Hygienist
    • Mouth Guards
  • Opening Times
  • Fees
  • Emergencies
  • Feedback
  • Updates & Policies
    • News and Updates
    • Policies
    • Medical Questionnaire
  • Contact
Practice Opening Times
The practice is closed for lunch from 1pm – 2pm Monday to Wednesday and 1pm – 1:30 pm Thursday and Friday.

 

Mondays & Tuesday
Wednesday
Thursday & Friday
Saturday
Sunday
8.00 am – 6.00 pm
8.00 am – 5.00 pm
8.00 am – 5.30 pm
By appointment only
Closed

Out of Hours, call 111

The premises are situated on the ground floor giving good access to the elderly and wheelchair patients.

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