Patient's Details



    Medical History

    • Your answers will help our surgeons provide you with the most appropriate treatment
    • The information you give is strictly confidential
    • Your honesty may assist in avoiding health problems


    • UnsureNoYes
      If yes, please tick where appropriate
      Heart diseaseHigh blood pressureRheumatic feverAsthmaDiabetesKidney diseaseHepatitisEpilepsyAnaemiaOsteoporosisOther prolonged illness, please give details

    • UnsureNoYes
      If yes, please tick where appropriate
      PenicillinPain killersIodineAnti-inflammatoriesCodeineLatexOther medication/drug/substance, please give details

      Reactions: RashSwellingVomitingOther, give details

    • UnsureNoYes


    • UnsureNoYes


    • UnsureNoYes

    • UnsureNoYes


    • UnsureNoYes
      If yes, please tick where appropriate WarfarinAspirinPlavixAny other blood thinning medication

    • UnsureNoYes

    • UnsureNoYes

    • UnsureNoYes
      0-55-1010 or more

    • UnsureNoYes
      < 1020-3030-6060+

    • UnsureNoYes

    • UnsureNoYes

    • UnsureNoYes



    • Additional Information Required

    • NoYes


    • Parents Details

      Accounts for patient will be issued under parents name.






    • HospitalDental/Extras






    • Dentist (as above)GP (above)Other (please enter details below)

    • If you have a copy of your referral please upload here


    • If you have a copy of your x-ray imaging please upload here


    •