Latchford and Latchford Patient Medical History Form

Latchford and Latchford Dental Practice in Bedford

Confidential Medical History Form

Please fill in the form below in full, when finished, simply click the green submit form button at the bottom of the page.

Personal and Doctors Details

Full Name *

Your Email

Your Telephone

Your Work Telephone

Your Mobile Number

Your Address *

Your Date of Birth *

Your Occupation

Doctors Name *

Doctors Postcode/Location *

Medical Questions

Are you...

Are you pregnant? *

Pregnancy Details

Are you receiving treatment from a doctor, hospital or clinic? *

Details of any treatments

Are you taking any medicines? *

Medicine Details

Have you...

Have you any infection or disease including HIV and Hepatitis? *

Infections/Diseases Details

Have you allergies to any medicines and materials? *

Allergy Details

Have you hayfever or eczema? *

Hayfever/Exzema Details

Have you bronchitis, asthma or chest condition? *

Bronchitis/Asthma/Check Condition Details

Have you any heart problems including angina, blood pressure? *

Heart Problem Details

Have you diabetes (or does anyone in the family)? *

Diabetes Details

Have you arthritis? *

Arthritis Details

Have you bruising of persistent bleeding? *

Bruising/Bleeding Details

Have you had a stroke? *

Stroke Details

Have you any fainting, giddiness or epilepsy? *

Fainting/Giddiness/Epilepsy Details

Have you rheumatic fever? *

Rheumatic Fever Details

Have you had liver disease (including jaundice and hepatitis)? *

Liver Disease Details

Have you had kidney disease? *

Kidney Disease Details

Have you been hospitalised? *

Hospitalised Details

Have you had a bad reaction to anaesthetic? *

Anaesthetic Details

Have you smoked? *

Smoking Details

Have you any other condition we should know about? *

Other Condition Details

Consents and Disclaimer

Receive Text Message Reminders

Our patients appreciate appointment reminders sent by text message. If you would prefer NOT to receive these messages you may opt out by ticking this box (but please remember that we do charge for wasted surgery time).

Anonymous Sharing for Research/Education

Our specialists are actively involved in research and education. Patients are usually pleased to allow us to use records while maintaining anonymity. If you prefer us NOT to use your records in this way please tick the box.

Contact Me

We have provided you with full information including terms and conditions of payment through our website and leaflets. If you feel uncertain about any aspect please tick here for a member of staff to contact you.

Disclaimer *

I confirm the information is correct

To the best of my knowledge this information is correct and I give my permission for the dentist or anaesthetist to contact my doctor and to check any medical record available.

Phone

25945

Data Protection

We take your and the privacy of our patients very seriously and have policies, procedures and the infrastructure in place to protect any information and documents provided to us. We are fully complaint with the GDPR legislation and other applicable data protection regulations. For more information, please click here to view our full privacy policy.