Taylors Rd Dental || DENTAL & AESTHETIC CLINIC

Creating Beautiful Smile with Exceptional Care

Medical History Form

Please complete the patient medical history form below. This information helps us provide safe and effective dental care tailored to your needs.

First Name *

Surname *

Date of Birth *

Address *

Postcode

Email Address *

Mobile Phone *

Employer

Employer Phone No.

Diabetes High Blood Pressure Heart Problems Asthma Arthritis Thyroid Problems Osteoporosis Anxiety Pregnancy Cancer Smoking/Vaping Allergies

Are You Pregnant?

Yes No

Due Date

If you have allergies or medical conditions please provide details

Name of Current Dentist/Practice

Date of Last Visit

Reason for Visit

Have You Had Any Complications Following Previous Dental Treatment?

Are You Anxious About Dental Treatment? (1 = Not anxious, 10 = Very anxious)

1 2 3 4 5 6 7 8 9 10

I authorise the dental staff to undertake examination, x-rays and treatment as required.
I understand treatment plans may vary depending on diagnosis.
Payment is required on the day of treatment unless otherwise arranged.
All information provided is true and correct to the best of my knowledge.

Name of Patient *

Signature *

Date *

Providing trusted dental and aesthetic care with a focus on comfort, quality, and long-lasting results.

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