New Patients | Oral Care Company

First name

Last name

Guardian Name (If Under 16)

Email

Mobile Phone

Work Phone

Address

Birthday

Day

Month

Year

Do you smoke?

Yes

No

Have you been under the care of a doctor / medical professional lately? If so why?

Have you ever had contact with: HIV, Hepatitis A, Hepatitis B, Hepatitis C

Yes

No

Have you ever experienced excessive bleeding or bruising from dental treatment, or at any other time?

Yes

No

Have you ever had a reaction/allergies to medicines (e.g anaesthetic, penicillin) or other substances (e.g Latex) Please list

Are you taking any pills, tablets, medicines or drugs? Please list with amount taken.

Have you ever had treatment for osteoporosis or taken Bisphosphonates e.g Fosamax?

Yes

No

Woman: Are you pregnant? If so how many weeks?

Preferred Dentist

Dr Michael Reardon

Dr Rebecca Quinlan

Dr Albert Yen

I confirm that the information provided is true and correct to the best of my knowledge.

Yes

Signature

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