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?
YES NO
When was your last visit to the dentist?
Please let us know how you found out about us:
Google Central Park Medical Word Of Mouth Leaflet Facebook/ Instagram OTHER
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Please tick the box you find appropriate as the correct answer for the following questions:
Do you smoke?
YES NO Please provide details:
Are you / may be pregnant?( if you are a female)
YES NO Please provide details:
Do you have High or Low blood pressure?
YES NO Please provide details:
Do you suffer from a kidney condition?
YES NO Please provide details:
Do you suffer from a liver condition?
YES NO Please provide details:
Do you have allergies to any medication? (Penicillin, Clindamycin, other)
YES NO Please provide details:
Do you have other allergies?
YES NO Please provide details:
Do you take bisphosphonates? ( Fosamax, Actonel, Bonviva, etc)
YES NO Please provide details:
Have you any history of heart problems?(Heart valves , heart failure, angina , endocarditis, heart murmur, etc.)
YES NO Please provide details:
Have you any vascular disease?
(Thrombophlebitis, Stroke, Peripheral arterial disease, Haemophilia, Abnormal bleeding,etc )
YES NO Please provide details:
Have you any respiratory disease?
YES NO Please provide details:
Do you suffer from rheumathic disease?
YES NO Please provide details:
Do you suffer from an endocrine disease?
YES NO Please provide details:
Do you suffer from any neurological condition?( Epilepsy , other)
YES NO Please provide details:
Do you suffer from any mental condition? (Depression, Schizophrenia, other)
YES NO Please provide details:
Are you allergic to any local anaesthetics? (Dental injections)
YES NO Please provide details:
Have you been tested positive for: Hepatitis B, Hepatitis C, HIV
YES NO Please provide details:
Are you currently undergoing any kind of treatment? Are you on any medication?
YES NO Please provide details:
Is there anything else you feel that we should be notified about which may affect your dental treatment?
YES NO 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.
YES NO
Consent* [Mandatory]:
I understand and agree that I am responsible for all fees and that they are payable on treatment unless otherwise agreed.
I am aware of and agree to the cancelation fees laid out in our Cancellation Policy I agree to the Terms and Conditions Privacy Policy
