Medical History Form

Your medical history can affect the success of your dental treatment and will guide us on how to provide safe treatment for you. The information you provide is completely confidential and will be handled in accordance with our privacy policy

Your Details

Preferred Name
Home Phone
Work Phone
 

Required for copy to be emailed to you
Occupation
If not known, please type unknown.

Emergency Contact

Confidential Medical History

Do you or have you ever had:

Current Medications


Please list any medications you may be taking (including herbal remedies, vitamins, supplements, cold/flu treatments, sleeping pills, pain relievers, injections, implants, contraceptives) so we can take appropriate precautions and avoid drug interactions.
Please state
Dose
Duration of treatment
Purpose

Allergies


Please state the drug name, nature of reaction and how long ago
Nature of reaction
How long ago?

Your privacy is important to us, all information submitted through this form is kept confidential