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Dental Implants
Teeth Straightening
Veneers
Teeth Whitening
Composite Bonding
Implant Dentures
Straightening
Invisalign
Quick Straight Teeth
Inman Aligner
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Smile in a Day Implants
Implant Dentures
New Patients
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Dermal Fillers
Anti Wrinkle Treatment
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I would like to
Straighten my teeth
Whiten my teeth
Fix my broken tooth
Fix my chipped tooth
Replace missing teeth
Replace my dentures
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I would like to
Straighten my teeth
Whiten my teeth
Fix my broken tooth
Fix my chipped tooth
Replace missing teeth
Replace my dentures
Register with you
3, Great Coleman Street, Ipswich, IP4 2AA
01473 597527
MEDICAL HISTORY FORM
YOUR MEDICAL HISTORY
Please fill out and submit the following form before arrival at our surgery.
Title
Title
Mr
Mrs
Miss
Master
Dr
Full Name
Date of Birth
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Address
Town/City
Postcode
Email
Telephone
Occupation
Name of Doctor
Address of Doctor
Next of Kin
Relationship to Next of Kin
Telephone of Next of Kin
Please tick any of the following conditions which apply to you:
Conditions
I am pregnant/possibly pregnant or have had a baby in the past 12 months
I have antibiotic cover requirement
I bruise easily or suffer persistent bleeding following a tooth extraction or injury
I am currently receiving treatment by a doctor, hospital or clinic
I am not OK to recline on dental chair
I am taking or have taken steroids in the past 2 years
I carry a medical warning card
I have been on a treatment requiring hospitalisation in the last 2 years
I have rheumatic fever or chorea
I have high blood pressure
I have had heart surgery or a heart stroke
I have a pacemaker fitted
I have a heart murmur
I have angina
I have thrombosis
I have another heart condition
I have bronchitis
I have cystic fibrosis
I have pleurisy
I have asthma
I have emphysema
I have pneumonia
I have had chest surgery or other chest conditions
I have liver disease (e.g jaundice, hepatitis)
I have diabetes (or someone in my family does)
I have acid reflux or an eating disorder
I have a bone or joint disease
I have fainting attacks or blackouts
I have had a serious or infectious disease
I have kidney disease
I have epilepsy
I have hiatus hernia
I have an artificial joint or other implants
I have giddiness
I have cancer
I require special needs (nervous, anxious, phobic)
My mother/siblings have a high number of caries
I have hepatitis B
I have H.I.V
I have had an abnormal blood test
I have had a reduced blood transfusion
I have anaemia
I have sickle cell
I have haemophilia or any other blood conditions
Please tick any of the following allergies which apply to you:
Allergies
Are you allergic to penicillin?
Are you allergic to hay fever?
Are you allergic to anti tetanus serum?
Are you allergic to eczema?
Are you allergic to general anaesthetic?
Are you allergic to local anaesthetic?
Are you allergic to latex?
Are you allergic to medicines?
Are you allergic to plants?
Are you allergic to any foods?
Are you allergic to aspirin?
If you smoke, how many per day?
What is your average weekly consumption of alcohol?
Please list any medication you are taking
Any other conditions, allergies or medication?
Please tick this box to confirm that the information submitted is correct
Please tick this box to confirm that the information submitted is correct
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I consent to my data being used in accordance to the
Privacy Policy.
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SUBMIT MEDICAL HISTORY FORM