1000" @mouseleave="menu = false" @scroll.window.throttle.50ms="atTop = (window.pageYOffset < 137) ? false: true">
News
Charity
Contact us
Google Translate
About us
Our sites & wards
Our services
Careers
Patients & visitors
Research
About us
About our history
Better together - our strategy, mission and values
Board of directors
Get involved
Equality, diversity and inclusion
Foundation Trust and membership
Information governance
Our Future Hospital Northern Devon
Safeguarding
Sustainability and environment
Our sites & wards
Acute Hospitals
Royal Devon and Exeter Hospital (Wonford)
North Devon District Hospital
Wards
Wards at RD&E (Wonford)
Wards at NDDH
Please use the link below to view other Trust locations
Our sites
Careers
Events and vacancies
Healthcare Support Workers
Allied Health Professionals
Nursing and Maternity
Medical and Dental
Healthcare Scientists and Pharmacy
Staff Bank
Other professional roles
Return to Practice
Volunteering
Patients & visitors
Accessibility, support & learning disability
Bereavement support
Carers
Chaplaincy (Spiritual, religious, and pastoral care)
Children and young people
Visiting information
Dementia and delirium
Help with health costs
Information and advice for people waiting for treatment
MY CARE
Outpatient appointments
Overseas patients
Patient information leaflets
Patient initiated follow ups (PIFU)
Video appointments
Private patients
Search
Search
News
Charity
Contact Us
Google Translate
About us
About our history
Better together - our strategy, mission and values
Board of directors
Get involved
Equality, diversity and inclusion
Foundation Trust and membership
Information governance
Our Future Hospital Northern Devon
Safeguarding
Sustainability and environment
Our sites & wards
Acute Hospitals
Royal Devon and Exeter Hospital (Wonford)
North Devon District Hospital
Wards
Wards at RD&E (Wonford)
Wards at NDDH
Please use the link below to view other Trust locations
Our sites
Our services
Careers
Events and vacancies
Healthcare Support Workers
Allied Health Professionals
Nursing and Maternity
Medical and Dental
Healthcare Scientists and Pharmacy
Staff Bank
Other professional roles
Return to Practice
Volunteering
Patients & visitors
Accessibility, support & learning disability
Bereavement support
Carers
Chaplaincy (Spiritual, religious, and pastoral care)
Children and young people
Visiting information
Dementia and delirium
Help with health costs
Information and advice for people waiting for treatment
MY CARE
Outpatient appointments
Overseas patients
Patient information leaflets
Patient initiated follow ups (PIFU)
Video appointments
Private patients
Research
Search
Home
>
Services
>
Salaried Dental Service
>
Referral forms
>
Medical history form
Services
Salaried Dental Service
Salaried Dental Service
Oral Health Information
Oral Health for you, parents and carers
Preparing for your dental appointment
Emergency dental service
Locations and contact
Referral forms
Referral from Dentist
Medical history form
Referral form Health or Social Care Professional
Oral Health training
Abdominal Wall Surgery
Acute Hospital at Home (AHAH)
Acute medicine
Acute Medicine Unit (AMU) - Eastern services
Anaesthetics
Audiology (hearing, tinnitus, and balance)
Bereavement services
Blood tests (phlebotomy)
Bowel and bladder care
Breast care
Cancer services
Cardiology (heart)
Castle Place Practice
Colorectal (rectum, anus and colon)
Community services
Critical care
Day surgery
Dental (teeth)
Dermatology
Diabetes and endocrinology
Dietetics
Discharge hub & Discharge lounge
Ear, nose and throat (ENT)
Emergency department (ED or A&E)
End of life care
Endoscopy
Fertility services
First Steps Nursery
Gastroenterology
Genetics and genomics
Gynaecology
Haematology
Healthcare for older people
Hepatology (Liver)
High dependency care
Infection prevention and control
Intensive Care Unit (ICU)
Learning disability services
Lymphoedema
Maternity and obstetrics (birth and babies)
Medical Assessment Unit - Northern Services
Medical Imaging (Radiology, X-ray)
Minor Injuries Unit (MIU)
Mobility and equipment services
Multiple Sclerosis
Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS)
Neonatal care
Neurology and neurorehabilitation
Nutrition and Dietetics
Occupational health and wellbeing
Occupational Therapy
Ophthalmology
Oral & maxillofacial
Organ donation information
Orthodontics
Orthopaedics
Orthotics (surgical appliances)
Outpatient services
Paediatrics (children and young people)
Pain management
Palliative care
Pathology
Pharmacy
Phlebotomy (blood tests)
Physiotherapy
Podiatry
Private patients
Radiology (X-ray and medical imaging)
Recovery from COVID-19
Renal and nephrology services (kidneys)
Respiratory
Resuscitation department
Rheumatology (musculoskeletal system / joints)
Safeguarding
Same day emergency care
Sexual assault referral centre (SARC)
Sexual health
Simulation
Specialist weight management service
Speech and Language Therapy (SLT)
Stroke
Surgery and theatres
Theatres
Therapies
Tissue viability (wound management)
Upper GI surgery
Urgent care
Urology (urinary tract)
X-ray (Medical Imaging, Radiology)
Vascular surgery
Nuclear Medicine - Eastern services
Ambulatory service
Neurophysiology
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?