Medical History

Middle Name/s

Gender

Email

Address

Occupation

Mobile Phone Number

Home Phone Number

Work Phone Number

Emergency Contact (Name)

Emergency Contact Phone Number

Name of General Dentist

How did you hear about us?

Do you smoke?

How much alcohol do you drink?

On average per week.

Has your dentist/specialist told you that you require antibiotics before extractions, cleans, or any dental work?

Are you pregnant now?

Have you ever had a reaction to anaesthetic?

Have you ever experienced excessive bleeding?

Please list any tablets, capsules, supplements, medicines, or drugs you are currently taking:

Are you allergic to any medicines or iodine?

The success of periodontal therapy is dependent on many factors including the severity of the periodontal destruction, the patient's general physical status, and the patient's ability and willingness to perform proper oral hygiene and stay on a recall programme after active treatment. As with treatment of any complex condition, especially where drugs and surgical procedures are being used, unusual and unanticipated problems can arise, such as bleeding, prolonged numbness, sensitivity to medications, sensitive or loose teeth and pulp damage. We will make every effort to keep you informed of the treatment necessary for you. Feel free to ask questions at any time. Your involvement and understanding are very important in the long-term success of your periodontal therapy.

Consent for Treatment

Please understand that by selecting 'Yes' on the following statements, you are signing the document. If you have questions about any of the statements, contact us before submitting the form.

Are you over 18?

Medical History

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With over 10,000 dental implants performed, our specialist team of periodontists and hygienists offer a range of cosmetic and reconstruction options to restore any smile.