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    Registration Form New Patient - New Version 05.22

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    hw2b7kncqx
    This document is a registration and medical history form for a new patient at a dental clinic. It requests information such as the patient's name, contact details, emergency contact, general practitioner details, how they heard about the clinic, current and past medical conditions and treatments, lifestyle factors like alcohol and tobacco use, and consent for appointment reminders and marketing communications. The patient is asked to provide full medical history and consent to share information with their GP.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Registration Form New Patient - New Version 05.22

    Uploaded by

    hw2b7kncqx
    4 views8 pages
    This document is a registration and medical history form for a new patient at a dental clinic. It requests information such as the patient's name, contact details, emergency contact, general practitioner details, how they heard about the clinic, current and past medical conditions and treatments, lifestyle factors like alcohol and tobacco use, and consent for appointment reminders and marketing communications. The patient is asked to provide full medical history and consent to share information with their GP.

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    Registration form New Patient - new version 05.22

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    This document is a registration and medical history form for a new patient at a dental clinic. It requests information such as the patient's name, contact details, emergency contact, general practitioner details, how they heard about the clinic, current and past medical conditions and treatments, lifestyle factors like alcohol and tobacco use, and consent for appointment reminders and marketing communications. The patient is asked to provide full medical history and consent to share information with their GP.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    4 views8 pages

    Registration Form New Patient - New Version 05.22

    Uploaded by

    hw2b7kncqx
    This document is a registration and medical history form for a new patient at a dental clinic. It requests information such as the patient's name, contact details, emergency contact, general practitioner details, how they heard about the clinic, current and past medical conditions and treatments, lifestyle factors like alcohol and tobacco use, and consent for appointment reminders and marketing communications. The patient is asked to provide full medical history and consent to share information with their GP.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 8

    Registration Form for new Patient

    PATIENT DETAILS:

    Your Name and Surname:


    Tel No:
    Email Address:
    Your Date of Birth:
    Your Address:

    EMERGENCY CONTACT:

    Name and Surname:


    Phone Number:
    Relative:

    CONFIDENTIAL MEDICAL HISTORY FORM

    GENERAL PRACTITIONER
     Address:

     Phone number:

     Letter to GP accepted? (yes or no):

    PLEASE FILL IN PERSON/PEOPLE WITH PARENTAL RESPONSIBILITY

    Your answer:

    1|Page
    WHERE DID YOU GET INFORMATION ABOUT VICTORIA DENTAL &
    HEALTHCARE LTD?

    Your answer:

    ***If you wish a chaperone to be present during your consultation or


    examination, please make a request at the reception

    Your answer:

    ARE YOU CURRENTLY:

     Receiving treatment from a doctor, hospital or clinic? (yes or no)

    Your answer:

    If yes Give details

    Your answer:

     Taking any prescribed medicines (e.g. tablets, injections, ointments or


    inhalers)? (yes or no)

    Your answer:

    If yes Give details:

    Your answer:

     Contraceptives or hormone replacement therapy? (Yes or no)

    If yes Give details

    Your answer:

    2|Page
     Carrying a medical warning card (yellow book)? (yes or no):

    If yes Give details

    Your answer:

     Pregnant or possibly pregnant? (yes or no):

    If yes Give details

    Your answer:

     Allergies to medicines (e.g. penicillin), substances (e.g. latex/rubber) or


    foods? (yes or no):

    If yes Give details

    Your answer:

     Bronchitis, asthma or other chest conditions? (yes or no):

    If yes Give details

    Your answer:

     Fainting attacks, giddiness, blackouts, epilepsy? (yes or no):

    If yes Give details

    Your answer:

     Heart problems, angina, blood pressure problems or stroke? (yes or no):

    If yes Give details

    Your answer:

    3|Page
     Diabetes (or does anyone in your family)? (yes or no):

    If yes Give details

    Your answer:

     Bone or joint disease? (yes or no):

    If yes Give details

    Your answer:

     Bruising or persistent bleeding following injury, tooth extraction or


    surgery? (yes or no):

    If yes Give details

    Your answer:

     Liver disease (e.g. jaundice, hepatitis) or kidney disease?

    If yes Give details

    Your answer:

     Any other serious illness or infectious disease (including HIV)? (yes or no):

    If yes Give details

    Your answer:

     Blood refused by the Blood Transfusion Service? (yes or no):

    If yes Give details

    4|Page
    Your answer:

     A bad reaction to general or local anaesthetic? (yes or no):

    If yes Give details

    Your answer:

     Treatment that required you to be in hospital? (yes or no):

    If yes Give details

    Your answer:

     Heart surgery? (yes or no):

    If yes Give details

    Your answer:

     Other ... (anything do you want to report)?

    If yes Give details

    Your answer:

    5|Page
    ALCOHOL
    How many units of alcohol do you drink per week? (A unit is a half pint of lager, a
    single measure of spirits or a single glass of wine)

    Your answer:

    SMOKING
    Do you smoke any tobacco products?
    Your answer:

    If so, how many per day:


    Your answer:

    Do you chew tobacco, use gutkha or supari?


    Your answer:

    If so, please specify and state how much per day:


    Your answer:

    Please give any other details, such as self-prescribed medications or any


    disabilities you may have.

    Your answer:

    Date: _____________________ Signature: _________________________

    6|Page
    GENERAL DATA PROTECTION REGULATION

    The laws around the General Data Protection Regulation and how
    we contact you have changed. At Victoria Clinic & Healthcare ltd we have
    introduced new ways to contact our patients including text messages,
    email appointment reminders and the occasional special offer via email
    or text. We are also looking to introduce a newsletter with further
    information and special offers for our patients. We are very careful with
    our patient's data and only share this information with appropriate
    healthcare professionals (GP, hospital, laboratory,) as we know how
    important your privacy is.

    Because of these new laws (GDPR) introduced, we have to


    specifically ask if you would like us to continue contacting you by email
    and/or text message in relation to your appointments, newsletters or
    any special offers. We would appreciate it if you could spend a few
    moments filling in the form below to allow us to continue contacting you
    via these methods.

    Please note If you change your mind and would like to change how
    we communicate with you in the future it can easily be done by
    contacting the practice or filling this form in again.

    First Name:

    Last Name:

    Date of Birth:

    7|Page
     Consent to be contacted for appointment reminders + sent
    information by phone or text message (Yes or no)

    Your answer:

     Consent to be contacted for appointment reminders + Information


    by email or letter (Yes or no)

    Your answer:

     Consent to be contacted by email and text message for


    newsletters, special offers and marketing information (Yes or no)

    Your answer:

    Date: _____________________ Signature: _________________________

    Print Name: ______________________________________________

    8|Page

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