Health Risk Assessment22 | Singleton Dental Practice & Implant Centre

Health Risk Assessment22

Home
Dental Implants at Singleton
About
Contact
Singleton Dental Training
Document downloads
Singleton Team Login
Health Risk Assessment22
Charity works

Home
Dental Implants at Singleton
About
Contact
Singleton Dental Training
Document downloads
Singleton Team Login
Health Risk Assessment22
Charity works
More
- More child

SINGLETON DENTAL PRACTICE

Dental Implants, Orthodontics & Aesthetics

Tel: 01233629516

Medical Health Assessment

Please complete the following questions for risk assessment and consent prior to attending Singleton Dental. Your answers will be recorded in your dental records held by Singleton Dental, and will be used to help provide you with correct and safe dental treatment.

Title *

Name *

Date of birth *

Address *

Postcode *

Phone *

Email *

Do you currently have a respiratory infection. e.g. Covid 19, influenza, common cold *

Please list all medications prescribed to you by your GP. Please write none if none are taken. *

Have you ever had or do you have the following conditions? Tick all that apply. *

Heart trouble or high blood pressure

Diabetes

Asthma

Epilepsy

Allergies to medications or other substances

Dental anxiety

Mental illness

Blood clotting disorder or taking anticoagulant medication

None of the above

Are you pregnant? If so please give your estimated delivery date.

Do you smoke, vape or use recreational drugs? *

Do you know if you have ever contracted a blood borne virus such as Hepatitis or HIV? *

Please give details here of any other medical conditions:

Consent to dental treatment: I am aware that this information will be used by the dentist to help provide me with appropriate and safe dental care. *

I confirm my consent.

some-randome-random

HOME