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Salaried Dental Service
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Medical history form
Details
Part 1 of 4
Surname
*
First name(s)
*
Sex
*
Male
Female
Other
Date of birth
*
Is the patient’s weight likely to be more than 22 st/140 kg?
*
Yes
No
NHS number
Address
*
Postcode
*
Email
*
A copy of this form will sent to this email address.
Home telephone number
Mobile number
Is the patient happy to receive SMS (text) notifications?
Yes
No
Where have you lived in the past 12 months?
*
Occupation or school
*
Next of kin name
Contact telephone number
Relationship of next of kin to the patient
Doctor’s name, address & telephone number
Do you have a social worker?
Yes
No
Please give a name & telephone number
Do you have a Lasting Power of Attorney for health?
Yes
No
How long is it since you last received dental treatment?
Where was this?
Last updated: October 10, 2023.
