Kids Consultation FormSimplyTeeth Essex, Online Consultation Form for Existing PatientsThank you for choosing SimplyTeethAs part of our attempt to reduce contact time and decrease the rate of infection, we are asking all patients to prefill Covid Risk assessments and medical history forms. Please fill and sign and submit these secure forms so that they can be loaded onto your record cards before your visit.You may experience increased waiting times as we will try and minimise the amount of patients we see, and you may be asked for deposits in advance for the increased price of PPE to be done over the phone prior to your visit.Please help us to keep both you and Us safe.In these uncertain times we want to make your journey as easy as possible. We offer payment plans of upto 12 months on all treatments over £250 and we are also open evenings till 9pm and Saturdays till 1pmPlease answer all questions. How did you hear about us? Full Name Date of Birth Address Contact Number Email Which practice would you like to contact? IllfordHornchurchMedical QuestionnaireAre you currently receiving treatment from a doctor, hospital or clinic? YesNoAre you currently taking any prescribed medicines (e.g. tablets, ointments or contraceptives and hormone replacement therapy)? YesNoIf YES, please mention what medicines. If NO, please type N/A Are you carrying a medical warning card? YesNoDo you suffer from allergies to any medicine (e.g. penicillin), substances? YesNoDo you suffer from hay fever or eczema? YesNoDo you suffer from bronchitis, asthma or any other chest conditions? YesNoDo you suffer from fainting attacks, giddiness, blackouts or epilepsy? YesNoDo you suffer from heart problems, angina, blood pressure problems, or strokes? YesNoAre you diabetic (or is anyone in your family)? YesNoDo you suffer from arthritis? YesNoDo you suffer from bruising or pesistent bleeding following injury, tooth extraction? YesNoDo you suffer from any infectious diseases (including HIV and hepatitis)? YesNoHave you ever had rheumatic fever or cholera? YesNoHave you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease? YesNoHave you ever had any other serious illness? YesNoHave you ever had blood refused by the Blood Transfusion Service? YesNoHave you ever had a bad reaction to general or local anesthetic? YesNoHave you ever had joint replacement or other implant? YesNoHave you ever had treatment that required you to be in hospital? YesNoHave you ever had heart surgery? YesNoHave you ever had brain surgery? YesNoDo you have any close relatives (parent, sibling, grandparent) who have had creutz jakob disease? YesNoIs there any other information which your dentist might need to know about your prescribed medicines (e.g. aspirin) YesNo Next of kin Full Name Relationship to Patient Contact Number GP Details GP Name Practice Name GP Contact Number I confirm that all the information I have provided here is correct to the best of my knowledge and that I agree to the terms and conditions of SimplyTeeth Essex.This form is filled in by: Send SimplyTeeth Essex is featured in several media covers. Read more.
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