0113 261 4228
Please only complete this form if we have requested you to do so.
What's your title?
What's your first name?
What's your last name?
What's your date of birth?
What's your gender?
What's your address?
What's your postcode?
What's your phone number?
What's your email address?
Who is your GP?
Are you taking any medication (tablets, medicines or drugs)? If yes, please list:
Have you any allergies to medicines ie penicillin, substances or materials (latex/rubber)?
Do you have or have you had any of the following?
Congenital heart lesion/ cardiac pacemaker
Heart attack/ angina/stroke
High blood pressure
Low blood pressure
Asthma or hay fever
Hiatus hernia/ stomach trouble
Jaundice, hepatitis, liver disease
Diabetes – low blood sugar
Bone or joint disease
Please answer the following:
Are you pregnant or is it possible you may be pregnant?
Are you taking contraceptive pill? Certain medication may compromise its effectiveness.
Are you taking or have you taken steroids in the last two years?
Have you ever had a prolonged illness or been hospitalised?
Have you had any major/serious operations or radiation therapy?
Do you have or have you had any contact with Hepatitis or HIV/AIDS carriers which is likely to put you at risk from either of these viruses?
Did you as a child or since have brain surgery, growth hormone treatment before the mid-1980s or have a close relative with CJD?
Have you ever had any ill effects following dental treatment?
Have you or any relation had any severe prolonged bleeding problems?
Have you had any ill effects from local anaesthetic?
Have you ever had any ill effects from aspirin?
Do you smoke / previously smoked any tobacco products or chew tobacco, pan/betel nut or other similar products?
Do you drink alcohol?
Is there any other information about your medical history which may be important?
Consent to dental treatment during COVID-19.
I am aware that the current COVID-19 pandemic brings a number of known risks and a number of unknown risks. I have chosen to seek dental treatment during the pandemic in the knowledge that much is still unknown about the virus.
I understand the coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly infectious. I also understand that some people may have the virus but may not ever have any symptoms. I therefore understand it is impossible to determine who has the virus and I understand that I must assume that anyone anywhere could be infected and infectious.
I confirm that I am not currently suffering from any of the following symptoms of Covid-19 and I have not suffered from any of these symptoms in the last 7 days? (• Fever (a temperature of 37.8 degrees centigrade or above). • A new persistent dry cough. • Muscle pains. • Headache. • Shortness of breath and breathing difficulties. • Severe pneumonia. • Loss of taste and/or smell. • Extreme fatigue. • Runny nose. • Sore throat)
I confirm that I have not been in close contact (within 2 metres) of anyone suffering with any of these symptoms in the last 14 days
I understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing of at least 2 metres is not achievable during treatment
I understand that some people are considered to be at greater risk of serious illness or higher mortality if they contract COVID-19 and I understand that these are individuals who: (• Have pre-existing medical conditions such as heart and circulatory disease. • Have high blood pressure. • Have diabetes. • Are very overweight. • Are male. • Are over 60 years of age. • Are from a black, Asian or minority ethnic (BAME) background. )
I understand that the dentist will take every precaution to make sure my treatment is provided according to strict clinical protocols and hygiene procedures
I understand and agree to The Parade Patient Agreement which all registered patients of the practice are subject to.
View the full agreement here.
I consent to the treatment being provided during the current phase of Covid-19.