medical history

confidential medical history form

We ask you for information about your general health to help us treat you safely.

Please complete this form fully then sign on the back page.

We will use this form at later visits to discuss any changes in your general health.

All information will be kept strictly confidential by the people caring for you and will only be shared with other health care professionals relating to your treatment.

Medical History Form

Title *

First Name

Surname

Choose your gender

Male

Female

Choose your gender

Date of Birth *

Parent / Guardian Name

Address

Post Code

Home Tel *

Work Tel *

Mobile Tel *

Email *

School / Occupation *

GDPR Notice 1

In order to comply with data protection regulations, I give my consent for Orthodontics For you to use my mobile phone number for the purpose of sending me text message appointment reminders and information regarding my healthcare provision.

GDPR Notice 2

I understand that it is my responsibility to keep my personal data up to date by informing Orthodontics For You if my mobile phone number, address or email address changes

In the event of an emergency, please contact

Name

Tel *

Relationship to you

Doctors details

Doctor details - Name *

Doctor details - Tel *

Doctor details - Postcode *

Doctor details - Address *

Dentists details

Dentists details - Name

Dentists details - Tel