Medical History

Please complete the Medical History in order to provide the best and safest treatment. Your clinician needs to know of any problems which may affect your treatment.  Any field with * must be completed, the form will not allow you to submit if not completed.

If you have Dental Insurance your insurance company may contact us from time to time to confirm the treatment you have received. Do we have your permission to converse with them?
Do we have your permission to leave answering machine messages on your home phone?
Are you attending or receiving treatment from a doctor, hospital, clinic or specialist? If yes complete Medical Treatment Details.
Are you taking any medicines, tablets, drugs or injections or using any creams, ointments or inhalers? Please enter details in Medications List.
Are you taking or have you taken steroids in the last 2 years? If yes please give details.
Do you carry a warning card? If yes please give details.
Are you pregnant or a nursing mother? If yes please give details.
Are you allergic to any medicines (eg Penicillin), materials (eg Latex) or foods? If yes please give details.
Do you suffer from bronchitis, asthma or other chest condition? If yes please give details.
Do you have fainting attacks, giddiness, blackouts or epilepsy? If yes please give details.
Have you ever been told you have a heart murmur, heart problem, angina or high blood pressure? If yes please give details.
Do you have diabetes or does anyone in you immediate family? If yes please give details.
Do you have any bone or joint disease? If yes please give details.
Do you bruise easily or suffer persistent bleeding following a tooth extraction or injury or does anyone in your family? If yes please give details.
Have you had jaundice, liver or kidney disease or hepatitis? If yes please give details.
Any other serious illness or infectious disease? If yes please give details.
Have you ever had your blood refused by the Blood Transfusion Service? If yes please give details.
Have you ever had a bad reaction to a local or general anaesthetic? If yes please give details.
Have you been hospitalised for any reason? If yes please give details.
Do you have a pacemaker or have you had heart surgery? If yes please give details.
If you do not drink enter 0
Do you smoke any tobacco products now (or did you in the past)? If yes enter quantity smoked per day.

This form is submitted to a secure email address. No details are kept on this server.

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As many of you are aware the remaining covid-19 restrictions are being lifted as of 19/07/2021. However, as a healthcare setting we have a duty of care to maintain patient safety, due to this NHS England have advised dental services to not change their guidelines, this means that all patients must still:

Call the practice mobile to let us know that you are outside or knock on the door and stand back

Adhere to social distancing rules

Wear a face covering (unless exempt) until seated in surgery

Hand sanitise upon entering and leaving the practice

If you have any questions or would like to or would like to discuss this further please call the reception team on: 01928733974 or send us an email to: reception@mainstreetdental.co.uk

We once again thank you for your cooperation.

Please check the Coronavirus Page for details of arrangements for emergency dental care.

Just to keep you updated:
Please see our updates on our Coronavirus page

Keep safe – Keep well – Keep brushing.

Main Street Dental Team

At your next visit why not ask about teeth whitening.

Did you know that teeth whitening is only legally carried out by a qualified Dental Professional?

Do not compromise.

 

Opening times during the festive season.

The practice will close after Monday 23rd December.

The practice will re-open on Thursday 2nd January 2020.

During this closure, patients of the practice may phone for details of the emergency numbers.

Please note that the call-out fee is £80 plus the cost of any treatment.