Medical History Form - Lighthouse Dental Practice

Title

Surname

Forename(s)

Date Of Birth

Mobile Number

I give permission to be contacted on the telephone number

Address

Postcode

Please include your postcode

Occupation:

Do you require the stairlift ?

(requirement under 120kgs)

Where did you hear about us?

GP Details

Would you like to register as an NHS or PRIVATE PATIENT?

NHS PATIENT

PRIVATE PATIENT

Female patients

Are you a mother of a child under 12 months?

Yes

Are you expecting a baby?

Yes

If yes please specify the due date:

COVID-19 ASSESSMENT - Do you have any of the following symptoms of Covid 19:

New continuous cough, high temperature above 37.8, change in taste or smell, sore throat or have you been diagnosed or had Covid-19?

Yes

If you have answered yes then please give details below:

Are you vulnerable or shielding or would you consider yourself high risk?

Yes

NHS Patients Under NHS regulations, we are unable to charge NHS patients who fail to attend for their initial appointments or who cancel at short notice (less than 24 hours notice is insufficient notice). A patient who fails to attend their new patient appointments or cancels at short notice, may not be offered any further appointments at this practice, but you may seek another NHS practice elsewhere. Please sign below to acknowledge this statement.

I agree to the photographs being taken by Lighthouse Dental Practice Ltd and consent to their use for the purposes described below, and in accordance with current data protection legislation. When used for any purpose not directly related to my care, the photographs will be made anonymous by obliterating the face so that I cannot be personally identified when they are used in lectures or publications which will include: - Clinical purposes relating to my treatment and kept with my confidential dental records, for teaching purposes with other dental professionals, for demonstrating clinical techniques and for Social Media - https://www.lighthousedental.uk/gdpr-policy/

I consent

I do not consent

Declaration

I hereby apply to become a patient of Lighthouse Dental Practice. I undertake to settle all fees when due. I understand that interest may be paid on overdue accounts and that seriously overdue accounts may incur extra fees.

Signed By:

Dated: