Gentle Affordable Quality Care - Call 09 626 6622

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Email

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Message

Please enter your details into this form. We will be sent an email from this site. You will need to book with us by calling 626 6622 or go to the book online page. Thank you.

Please enter your full name

Please enter your date of birth, D/M/Y

Click to enter an email address

Click to enter mobile phone number

Click to enter home phone number

Please enter you home address

How did you find our practice?

Do any of these options apply to you? Please check appropriate box.

Do you require antibiotics before dental treatment?
Do you smoke?
Are you pregnant?
Have you had abnormal reactions to anaesthetics?
Have you had or are you having Steroid therapy?
Have you had Rheumatic Fever?
Have you had or do you have Epilepsy?
Have you had or do you have Asthma?
Have you had or do you have a Heart Disorder?
Have you had or do you have Bone Disease?
Have you had or do you have Diabetes?
Have you had or are you having Radiation Therapy?
Have you had or do you have Kidney Disease?
Do you have a Bleeding Disorder?
Have you had a Stroke?
Have you had or do you have Cancer?
Have you had or do you have Thyroid Disease?
Do you have Snoring/sleep Apnoea?
Do you have High/low Blood pressure?
Have you had or do you have Anxiety/depression?
Do you have a joint replacement?
Do you have a cardiac pacemaker?
Do you have a Stomach or digestive condition esp reflux?
Do you have Hepatitis/liver disease?
Do you have Blood borne virus (HIV etc)?
Do you have Bronchitis, emphysema other lung disorder?
Do you have Anaemia, leukaemia etc?
Have you received an organ transplant?
are you taking any anticoagulant medication (blood thinners)?

Please list any ALLERGIES you have.

Please list any medications you are taking.

Who is your medical GP?

Please list any other medical conditions that may be relevant to your dentist.

Authority

I confirm I am authorised to fill this form in for the applicant and all information is accurate.