Registration Form -

Name *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Date of Birth

Email

Name of Doctor

Emergency Contact

Practice Name

Emergency Contact Phone

Practice Phone

Relationship

Habits

Smoke tobacco products? (Per day)High sugar/frequencyChew tobacco, pan, gutka, supari (Per day)Lots fizzy/acidic drinksConsume alcohol? (Units per week)Recreational drugsOther habts

Other

Heart

Rheumtic FeverHeart MurmurHigh Blood PressureAnginaHeart SurgeryThrombosisPacemaker FittedOther Heart condition

Other

Blood

Hepatitis BAnaemiaH.I.V.Stckle CellAbnormal Blood Test ResultHaemophiliaBlood refused by transfusion serviceOther Blood condition

Other

Allergies

PenicillinLatexHay FeverMedicinesAnti-Tetanus SerumPlantsEczemaFoodsReaction to General AnaestheticAspirinReaction to Local AnaestheticOther Allergy

Other

Warnings

Pregnant or possibly pregnantProblem being reclinedAntibiotic Cover requiredSteroids in last 2 yearsAnything else your dentist should knowWarning CardBrusing or persistent bleeding after injury, surgery or tooth extractionBrusing or persistent bleeding after injury, surgery or tooth extractionCurrently under treatment of a doctor, hospital or clinicAny other treatment that required you to be hospitalised

Other

Chest

BronchitisEmphysemaCystic FibrosisPneumoniaPleurisyChest SurgeryAsthmaOther Chest Condition

Medication

List and state doses for any prescribed medicines, tablets, injections or inhalers (Inc. contraceptive and HRT) you are taking.

Other

Liver Disease (e.g. jaundice)Kidney DiseaseDiabetes/Family with DiabetesEpilepsyAcid Reflux or Eating disorderHiatus HerniaBorneo Joint diseaseArtificial JointFainting Attacks or BlackoutsGiddinessAny past Serious or Infectious diseaseCancer

Other

Registration Form

Confidential Medical History

Verification