Title

First Name

Last Name

Date of Birth

Occupation

Address

Post Code

Telephone

Email Address

How did you hear about MiSmile Birmingham?

I wish to be contacted by MiSmile Birmingham for offers or appointment reminders

Via PhoneVia EmailVia Post

Health Questions

Please answer the following questions

Are you currently pregnant?

YesNo

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

YesNo

Are you taking any prescribed medicines (e.g. tablets, injections, inhalers, contraceptive pill?

YesNo

Please give details of any medication

Do you carrying a Medical Health warning card?

YesNo

Allergies to any medicines (e.g. Penicillin), substances (e.g. Latex/rubber) or Foods?

YesNo

Hay fever or eczema?

YesNo

Bronchitis, asthma or other chest conditions?

YesNo

Fainting attacks, giddiness, blackouts or epilepsy?

YesNo

Heart problems, angina, blood pressure?

YesNo

Diabetes? (or a family member)

YesNo

Please state family member and diabetes type

Bruising or persistent bleeding following injury, tooth extraction or surgery?

YesNo

Any infectious diseases? (Including HIV and hepatitis)

YesNo

Please state any infectious diseases

Gastric ulcerations?

YesNo

Do you smoke?

YesNo

If so, how many per day

Do you drink alcohol?

YesNo

If so, how many units per week

Please give any other information you think the dentist might need to know about below

Signature

Sign with your finger if you are on a mobile or tablet, or click and drag with your mouse if you are on a computer.

Medical history

Health Questions

Give your smile
diamond treatment

Medical history

Health Questions

Give your smile diamond treatment

Give your smile
diamond treatment