Confidential Medical History Form

Please complete this form prior to your dental appointment.

For confidentiality, please do not enter your full name or full postcode - only insert your initials and the last three characters of your postcode as requested.

Do you currently, or have you ever taken, any of the following;

Do you suffer from, or have you ever suffered from:

(A unit is half a pint of lager, a single measure of spirit, a single glass of wine/aperitif)