Medical History – Update

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


Contact Details

GP Details

Medical History

Please answer all the below questions by ticking ‘yes’ or ‘no’. If you answer ‘yes’ to any questions please provide additional details in the
space indicated. All information provided will be kept strictly confidential.

Authorisation & Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in my medical status. I hereby authorise American Smilel to perform the examination and after explanation, any and all treatment for the above-named patient including radiographs if indicated and consent to such methods, drugs and agents that may be indicated in connection with his/her dental care as well as contacting me with detail of appointments time, planned treatment cost and appointment reminders via email, phone call and/or text message. This consent shall remain in effect until cancelled. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

Notice of Privacy Practices - How we may disclose your PHI (personal health information)

Heath Care Operations: We may use and disclose your PHI including x-rays, clinical photographs and clinical information for our own health care operations and other health care professionals involved in the provision of healthcare to you.

Business Associates: There are some services provided to our organisation through contracts with business associates, such as laboratory, dental practices or radiology services. We may disclose your PHI to our business associates to enable them to provide their services.

Individuals Involved with Your Care: We may disclose your PHI to family or others identified by you or who are involved in your care or payment for your care.

Legally Required Disclosures & Public Health: We may disclose your PHI as required by law, including to government officials to prevent or control disease, to report child, adult or spouse abuse, to report reactions or problems with products and to report deaths.

Payment: We may use and disclose your PHI to billing and collection agencies, insurance companies and health plans to collect payment for our services.

Changes to this notice: Please note that this consent can be withdrawn at any time


Photography will be taken before and after treatment, processed and stored and stored in accordance with the Data Protection
Act 2018. I give consent for the following to be taken and used (please tick all that apply):

*Your name or personal details will not be shared or published

Patient-only offers

Occasionally we organise patient-only events, provide discounts on current treatments or launch new innovative treatments. If you would like to be the first to know about our exclusive patient-only offers, please indicate how you would prefer to hear from us. Please note, you can unsubscribe from any type of communication at any time.

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