Medical Questionnaire

It is important for your clinician to have your medical history and understand your health needs before any examination or treatment is carried out.

Please kindly complete this medical questionnaire as fully and accurately as possible.  Your answers will be treated in the strictest confidence in accordance with the Data Protection Act

Patient Form
Please choose which practice is this appointment booked for.
Practice *

Patient Information

Address *
Address
City
County
Post Code

Parent/Guardian (if applicable):

Confidential medical history form

To obtain the best and safest treatment, we would like to know of any problems which may affect your treatment

Are you:

Have you ever had

Do you have any of the following:

Do you

1 pint of lager or a medium glass of wine= 2 units

Checked by the Orthodontist:

Section

If you wish to be contacted with news about treatments, what’s happening at the practice and informing you about our services and promotions please tick this box.

Our practice follows agreed procedures to keep your information secure and private. Your personal information will never be passed to third parties unless we are making a professional referral for you. For more information, please see our Privacy Notice published on our website www.LondonLovesBraces.com/privacynotice.