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Cosmetic, Implant and General Dentistry
First Name
Last Name
Date of Birth
City / Town
Postcode
Home Phone Number
Email Address
Occupation (optional)
Contact Number
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
Grinding Teeth YesNo
Sensitivity to Hot or Cold YesNo
Bleeding Gums YesNo
Broken Tooth YesNo
Clicking Jaw YesNo
Growth In Mouth YesNo
Food Collection YesNo
Have You Ever Had Any Serious Illnesses Or Operations
If Yes, When?
(Females) Are You Taking Birth Control Pills? YesNo
Shortness of Breath YesNo
Cancer YesNo
Thyroid Problems YesNo
Radiation Treatment YesNo
Hepatitis YesNo
Pacemaker YesNo
Circulatory Problems YesNo
Asthma YesNo
HIV/AIDS YesNo
Stroke YesNo
Congenital Heart Lesion YesNo
Bleeding Abnormally YesNo
Liver Disease YesNo
High Blood Pressure YesNo
Diabetes YesNo
Heart Problems YesNo
Headaches YesNo
Fainting YesNo
Cortisone Treatment YesNo
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
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
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