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Patient information form

Fill this in before your first visit and it is waiting for the dentist when you arrive. Prefer paper? Download the printable version, fill it in by hand and bring it with you.

Draft, awaiting review by Dr. Swapnil B. Patil, BDS

Download the printable form (PDF)All patient forms

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About you

Which clinic are you visiting?
For example: pain on the lower left when I chew, or a missing tooth I want replaced.

Your health

Some conditions and medicines change how we numb a tooth, whether an extraction or implant is safe, and how you heal. Tick anything that applies, now or in the past.

Do you have, or have you had, any of these?
Include blood thinners such as aspirin, and any bone medicines. If you are unsure of a name, bring the strip.
To medicines such as penicillin, to latex, or anything else.
Are you pregnant, or could you be?
Do you feel nervous about dental treatment?

Signature ____________________________

Date ____________________

They go to the clinic you chose, and nowhere else.
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