Date of Birth

Occupation (optional)

Reason for Visit

Date of Your Last Dental Visit

Name and Address of your GP

How Did You Hear About Usmile?

I Would Like To Have A Dental Examination

YesNo

I Would Like To Have X-Ray Image Taken From Me, To Support My Examination
YesNo

I Would Like To Have A Hygiene Treatment For The Costs Indicated By USmile
YesNo

Tick If You Have Or Had Any Of The Following Dental Problems

Food Collection
YesNo

Medical History

Have You Ever Had Any Serious Illnesses Or Operations

Do You Have Or Had Any Of The Following:

Please List Any Medications You Are Currently Taking:

Please List Any Allergies You Have (For Example, Latex, Aspirin, Penicillin)

Name of the Person Filling In This Form

Date of Birth of the Person Filling In This Form

Please Tick As Appropriate

To The Best Of My Knowledge, The Information Is Complete And Correct

I understand that if I fail to attend an appointment or fail to cancel less than 72 hours before my appointment, I will be charged £50 administration fee.

I agree that the information provided above can be used confidentially for medical and internal purposes by U Smile Dental Practice.

I have read, understood and agree to the privacy notice