Medical Form

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

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The state of your health may have a very significant effect on your dental care.  Please answer these questions fully or discuss them with your dentist:

I have private and confidential medical matters which I wish to discuss with the dentist
Are you recieving ay medical treatment at present?

Some medicines may interfere with your dental treatment or react with medicaments used by your dentist.  It is important that your dentist knows precisely which medications (if any) that you are taking.

Please list any medications you are currently taking, or have been taking recently including herbal remedies, vitamins, supplements, cold/flu treatments, sleeping pills, pain relievers, injections, implants, so we can take appropriate precaution and avoid drug interactions.

If you are in any doubt about your medication, please bring a Pharmacy Medication Summary or the medication packaging to the practice to show the dentist.

Please tick YES if you have ever had any of the following:
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DECLARATION:

In signing this form, I declare that this represents an accurate medical history.  I will advise my dentist of any changes made to my Medical history, treatment or medications.  I understand that all medical information will be treated with complete Confidentiality.  I have read the privacy statement provided by Bluff Point Dental.

Your Signature (parent/guardian if under 18 years)

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