Medical History Form

Tel: 0117 9238 400 | Email: info@rootfillings.com

Once the online form is filled, click the 'Send' button at the end which will send the form to us instantly.

Name *

Address *

Telephone contact number *

Mobile contact number *

Fax

Email *

Date of birth *

Occupation

Have you ever suffered from or had:

Heart problems, heart surgery, high blood pressure or rhumatic fever?

Blood or bleeding disorders?

Do you take Warfarin or any thinning medicine?

Chest or breathing problems, asthma, bronchitis or shortness of breath?

Jaundice, hepatitis or other liver disorders?

Stomach ulcers, or have you been instructed to avoid aspirin/ibuprofen?

Kidney problems?

Fits, epilepsy or other neurological problem?

Sickle Cell Disorder?

Sleeping disorders?

Diabetes?

If appropriate, could you be pregnant, are breast feeding?

Do you have any allergies? eg Latex

Are you allergic to Penicillin?

Have you ever had any adverse reaction to local anaesthetic or sedatives?

Do you have any other medical condition or relevance?

Please list below all medication that has been prescribed by your doctor/specialist?

Bristol Specialist Dental Clinic, 9 North View,
Westbury Park, Bristol, BS6 7PT

Tel: 0117 9238 400

Email: info@rootfillings.com

Opening times: Monday - Friday, 8am - 6pm