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information@finedondentalpractice.co.uk

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    Casual/Emergency and Direct Access Form

    Personal Details: MrMrsMissMsOther

    Surname:

    First name:

    Address:

    Postcode:

    Date of Birth:

    Telephone Number:

    Mobile Number:

    Email:

    Occupation:

    I authorise Finedon Dental Practice to communicate with my next of Kin/ carer/ power of attorney* (please delete as appropriate) Please enter N/A in each box if not applicable

    Their name:

    Relationship:

    Their contact number:

    *If you have selected Power of Attorney, please complete a Mental Capacity form.

    Permitted use of personal data


    In the event that any person working at Finedon Dental Practice wishes to use any of my personal data for use for marketing, promotional, educational, training or any other purpose than my care & treatment, I permit the practice management to make an information request to me using the following methods:


    I DO NOT permit the practice management to request using my personal data for any purpose other than my care & treatment.

    Certain medical conditions can affect dental treatment and vice versa.
    Please complete the medical history form.

    MEDICAL HISTORY

    COVID-19 TRIAGE. Do you currently have Covid 19? YesNo

    If you smoke, what is your average per week?

    What is your average weekly consumption of alcohol?

    Please tell the dentist if you are HIV positive YesNo

    Have you ever had a joint replacement operation? YesNoIf yes, please give details

    In the past 2 years have you been treated with hydro-cortisone or corticosteroids? YesNo

    In the past 2 years have you undergone any operations? YesNo If yes, please give details

    Are you at present taking any medicine or tablets? YesNo Please list below

    Are you allergic to any medicine, tablets, substances or latex?YesNo Please list below

    Do you carry a medical warning card? YesNo

    Do you have or have you ever suffered from any other serious illness? YesNo If yes, please give details

    Do you have or have you ever suffered from high blood pressure? YesNo

    Do you have or have you ever suffered from excessive bleeding? YesNo

    Do you have or have you ever suffered from hepatitis? YesNo

    Do you have or have you ever suffered from chronic bronchitis or asthma? YesNo

    Do you have or have you ever suffered from epilepsy or fainting attacks? YesNo

    Do you have or have you ever suffered from diabetes? YesNo

    Do you have or have you ever suffered from any heart complaint, heart surgery or stroke? YesNo If yes, please give details

    Are you pregnant? YesNo

    Do you have or have you ever suffered from rheumatic fever?YesNo

    Please include the name and address of your doctor

    PLEASE LIST ANY MEDICATIONS YOU ARE TAKING

    PLEASE LIST ANY ALLERGIES

    Patient’s name:

    Date: