Dental Experts Clinic is part of the state of the art multidisciplinary clinic Central Park Medical situated the superb Central Park Bussiness Park in Leopardstown.
Monday - Friday 8.00 - 17.00
WhatsApp Messages: +353874344837
email us: info@dentalexperst.ie
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Medical Questionnaire

Home  /  Medical Questionnaire

Confidential Medical & Dental Questionnaire
Private Patient

Medical Form

Fields marked with * are mandatory

    First Name*:

    Surname*:

    Date of birth*:

    PPS No:


    Home Adress*: E-mail Adress: Mobile Phone Number*: Home Phone Number: Your GP's Name and Address: Occupation: Do you hold a Private Dental Insurance? When was your last visit to the dentist? Please let us know how you found out about us:

    Please tick the box you find appropriate as the correct answer for the following questions:

    Do you smoke?

    Please provide details:

    Are you / may be pregnant?( if you are a female)

    Please provide details:

    Do you have High or Low blood pressure?

    Please provide details:

    Do you suffer from a kidney condition?

    Please provide details:

    Do you suffer from a liver condition?

    Please provide details:

    Do you have allergies to any medication? (Penicillin, Clindamycin, other)

    Please provide details:

    Do you have other allergies?

    Please provide details:

    Do you take bisphosphonates? ( Fosamax, Actonel, Bonviva, etc)

    Please provide details:

    Have you any history of heart problems?(Heart valves , heart failure, angina , endocarditis, heart murmur, etc.)

    Please provide details:

    Have you any vascular disease? (Thrombophlebitis, Stroke, Peripheral arterial disease, Haemophilia, Abnormal bleeding,etc )

    Please provide details:

    Have you any respiratory disease?

    Please provide details:

    Do you suffer from rheumathic disease?

    Please provide details:

    Do you suffer from an endocrine disease?

    Please provide details:

    Do you suffer from any neurological condition?( Epilepsy , other)

    Please provide details:

    Do you suffer from any mental condition? (Depression, Schizophrenia, other)

    Please provide details:

    Are you allergic to any local anaesthetics? (Dental injections)

    Please provide details:

    Have you been tested positive for: Hepatitis B, Hepatitis C, HIV

    Please provide details:

    Are you currently undergoing any kind of treatment? Are you on any medication?

    Please provide details:

    Is there anything else you feel that we should be notified about which may affect your dental treatment?

    Please provide details:

    Do you give your consent to being contacted by members of the Dental Experts Clinic in relation to your treatment? Contact with you is important for reminders, transfer of information to hospitals and others if required and requested by you.

    Consent* [Mandatory]:


    dental clinic dublin

    To be signed by Parent/Guardian in the case of a minor.

    Contact us for more information or book an appointment