Medical History Form

We ask you for information about your general health to help us treat you safely. Please fill out your contact details below, answer the health questions and then accept the terms in the last section. We will use this form at later visits to discuss any change in your general health. All information will be kept strictly confidential by the people caring for you.

Personal Details

MF

Contact Details

GP Details

Contact Authorisation

Please provide us with details of any person/s who are authorised by you to request information regarding your dental treatment, appointments and fees:

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