Use this form to outline your medical history to us. We use this information to make informed dental care decisions about you.

The form is submitted securely and your information is stored confidentially. Your information is only shared to other medical professionals if you give permission.

Personal Details

If you prefer to be called something other than your first given name listed above

Contact Details

General Medical

Have you ever had any of the following?

Cardiovascular

Respiratory

Other

Medical History

Have you ever had contact with:

Dental

Agreement

Our aim at QE2 Dental is to provide excellent dental care and service in a friendly, professional environment. For any reason if you feel that you have not received care and treatment to a high level then please inform us so we can do something about it.
Payment is required at the time of treatment unless prior alternatives have been arranged. If the account is unpaid after 28 days, the outstanding balance will be forwarded to a professional debt collection agency. Any further expenses incurred by this are your responsibility
We will ask you to sign the declaration on our premises.
Patients under 16 years need to have the declaration signed by a parent or guardian.

Before starting

You will need this information handy before completing the form:

  • your usual doctor's name and contact details
  • records or memory of any medical procedures you have had, diseases you have, allergies etc etc.

If you prefer to print out a form, download the PDF in the panel below. Then you can post, fax, or bring the completed form to our office.

Form download

First page of Confidential General and Health Questionnaire
Confidential General and Health Questionnaire (PDF, 117.5KB)

Print this form out, fill it in, and bring it in for us if you prefer.