Entry to the Waiting List Form

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You are not registered unless your seen for an full check up in the practice

Name *

Full Address with Postcode *

Date of Birth *

YYYY

Email *

Phone Number *

Are you Currently:Attending or receiving treatment from a doctor hospital or specialist? *

Yes

Taking any medicines from your doctor? (e.g., Warfarin, bisphosphonates or other tablets, ointments, injections or inhalers, including contraceptives and hormone replacement therapy?) If answer is yes please provide list of medication with dose and frequancy in next question

Yes

Clear selection

If answer for the last question is yes; please provide list of medication with dose and frequancy otherwise write NA *

Carrying a medical Warning card? *

YEs

Have You ever had:Allergies to medicine (e.g. Penicillin), substances (e.g. Latex/rubber) or foods? *

Yes

Other:

I get a rash with and I am allergic to : *

Have fainting attacks, giddiness, blackouts or epilepsy? *

Yes

Heart problems, angina, blood pressure problems, or stroke? *

Yes

Have diabetes or does anyone in your family? *

Yes

Bone or joint disease? *

Yes

Bruising or persistent bleeding following injury or tooth extraction? *

Yes

Liver disease (e.g. Jaundice, hepatitis) or kidney disease? *

Yes

Any other serious illness or infectious disease? *

Yes

A- Have You ever had:Blood refused by the Blood Transfusion Service or any other agency abroad? B-A bad reaction to general or local anaesthetic?C- Treatment that required you to be in hospital?D- Heart surgery or a stent?E- Any forms of mental illness (e.g. Anxiety, stress, eating disorders)? *

If answer to any above is yes please specify in the next question sace

Yes

If answer to any of the above question is yes please specify below otherwisw type NA *

Have you ever consumed alcohol? If yes How many units of alcohol consumed per week? If no write 0 *

EXCESSIVE ALCOHOL CAN CAUSE MOUTH CANCER AND OTHER HEALTH PROBLEMS> ON HOW TO CALCULATE UNITS VISIT https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/

Do you smoke tobacco products?Do you vape/use electronic cigarettes? (or did you in the past)? if applicable Please write a number of equivelant Cigrates per day. If never smoked write 0. *

SMOKING CAN CAUSE MOUTH CANCER Please specify if stoped smoking when did you stop

Pregnant ? *

Yes

Not applicable

Write Below Current Medications any any detais about any YES answer

EXEMPTION *

Please claim exemption before you see dentist, you can not apply retroperspectively after a charge is raised during your visit.

Yes

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