Medical-History - Chelsea Dental Studio CDS | Dental Implants and Cosmetic Dentistry Specialists in Chelsea London

02073511685
07543544883
info@chelseadentalstudio.co.uk

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PRACTICE
- ABOUT
- TEAM
TREATMENTS
PATIENT
BLOG
CONTACT

Medical and Dental History

(Mr/Mrs/Miss/Ms) Surname

Forename

D.O.B

Address

Postcode

Tel no (Home/Work/Mobile)

Email Address

Name & Address of Dentist

Name & Address of Doctor

Please complete this form by ticking the appropriate boxes and answering the questions;
All details will be strictly confidential.

Do you or have you ever suffered from:

Rheumatic fever?

Yes No

Any heart complaint (including heart murmur)?

Yes No

Diabetes?

Yes No

Epilepsy?

Yes No

Asthma?

Yes No

Hay Fever?

Yes No

Hepatitis?

Yes No

Jaundice?

Yes No

Excessive bleeding?

Yes No

High blood pressure?

Yes No

Are you allergic to any medicines or materials? (If yes, please give details)

Yes No

Are you at present taking any medication? (If yes, please give details)

Yes No

Have you; had any serious illnesses or operations? (If yes, please give details)

Yes No

Have you; had any previous Orthodontic Treatment? (If yes, please give details below)

Yes No

Are you or is there a possibility you could be pregnant?

Yes No

Are you a smoker, if yes how many cigarettes do you smoke per day?

Yes No

Approximate units of alcohol consumed per week?

Do you grind or clench your teeth? If yes, we strongly advise you to use a mouthguard.

Yes No

Do you play any contact sports? If yes, we strongly advise you to use a mouthguard.

Yes No

How did you hear about us?

Signature

Date

Chelsea Dental Studio brings the latest advancements in dentistry for you and your family. Our expert dentists and staff pride themselves on ensuring that each patient experiences the ultimate in individual, personalized dental treatment.

020 7351 1685

info@chelseadentalstudio.co.uk
295 Kings Road, Chelsea, London SW3 5EP

Dentistry

General Dentisry
Nervous Patients
Dental Filling
Family Dentistry
Emergency Dentistry
Dental Hygiene

Cosmetic Dentistry

Cosmetic Dentistry
Smile Makeover
Mac Veneers
Mouth Guards
Porcelain Veneers
Teeth Whitening

Dental Implants

Dental Implants
All on Four

Facial Aesthetics

Facial Aesthetics
Wrinkle Relaxing
Dermal Fillers
Dermaroller
Heart Lips™
Mesotherapy
Chemical Peels
OBAGI

Orthodontics

Orthodontics
6 Months Smiles
Damon Braces
Incognito™ Lingual Braces
Inman Aligner™
Invisalign®
Invisalign Teen®
Invisalign Lite®
Simpli5

We're Available

Mon. 10:00 am – 6:00 pm

Tue. 10:00 am – 5:00 pm

Wed. 10:00 am – 5:00 pm

Thu. 9:00 am – 7:00 pm

Fri. 9:00 am – 7:00 pm

Sat. 9:00 am – 2:00 pm

Sun. Closed

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Medical and Dental History

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