Choice Dental

Choice Dental

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Book Appointment (Detailed)

Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

This Detailed Booking Form is Required By Your Dentist @ Choice Dental

Please take a few minutes to complete this form in to help us ensure that the quality of care you’ll receive is excellent.

Emergency

0811 113 1200
0700 336 8478

Email

office@choicedentalng.com
care@choicedentalng.com

Working Time

Monday-Saturday
9AM - 7PM

Personal Info - Step 1 of 17

Title

Patient Name *

First

Last

Prefered Name

Gender *

Multiple Choice *

Adult (18yrs and above)
Child (Below 18yrs)

Birth Date *

Email *

Mobile Number *

Best time to call

Address

Preferred Appointment times

Day of the week

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Time of Day

Morning
Afternoon
Evening
Anytime

How did you here about us?

Dental Office
School
Signage
Work
Word of mouth
Social Media
Website

Other (Please specify)

Whom may we thank for referring you?

Name

Mobile Number

Patient's Medical History

Are you under a physician's care now? *

Yes
No

Please describe the problem or issue *

Have you ever been hospitalized or had a major operation? *

Yes
No

Please describe the problem or issue *

Have you ever had a serious head or neck injury? *

Yes
No

Please describe the extent *

Are you taking any medications, pills or drugs? *

Yes
No

Please describe the kind of medication or drugs *

Do you take, or have you taken, Phen-Fen or Redux? *

Yes
No

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? *

Yes
No

Are you on a special diet? *

Yes
No

Do you use Tobacco? *

Yes
No

Do you use controlled substances?

Yes
No

Pregnant or trying to get pregnant? *

Yes
No

Taking oral contraceptives? *

Yes
No

Nursing a baby? *

Yes
No

Are you allergic to any of the following? *

Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa Drugs
None
Other

Please explain *

Do you have, or have you had, any of the following?

AIDS/HIV Positive *

Yes
No

Alzheimer's Disease *

Yes
No

Anaphylaxis *

Yes
No

Anaemia *

Yes
No

Angina *

Yes
No

Arthritis/Gout *

Yes
No

Artificial Heart Valve *

Yes
No

Artificial Joint *

Yes
No

Asthma *

Yes
No

Blood Disease *

Yes
No

Blood Transfusion *

Yes
No

Breathing Problem *

Yes
No

Bruise Easily *

Yes
No

Cancer *

Yes
No

Chemotherapy *

Yes
No

Chest Pains *

Yes
No

Cold Sores/Fever Blisters *

Yes
No

Congenital Heart Disorder *

Yes
No

Convulsions *

Yes
No

Cortisone Medicine *

Yes
No

Diabetes *

Yes
No

Drug Addiction *

Yes
No

Easily Winded *

Yes
No

Emphysama *

Yes
No

Epilepsy or Seizures *

Yes
No

Excessive Bleeding *

Yes
No

Excessive Thirst *

Yes
No

Fainting *

Yes
No

Spells/Dizziness *

Yes
No

Frequent Cough *

Yes
No

Frequent Diarrhea *

Yes
No

Frequent Headaches *

Yes
No

Genital Herpes *

Yes
No

Glaucoma *

Yes
No

Hay Fever *

Yes
No

Heart Attack/Failure *

Yes
No

Heart Murmur *

Yes
No

Heart Pacemaker *

Yes
No

Hemophilia *

Yes
No

Hepatitis A *

Yes
No

Hepatitis B or C *

Yes
No

Herpes *

Yes
No

High Blood Pressure *

Yes
No

High Cholesterol *

Yes
No

Hives or Rash *

Yes
No

Hypoglycemia *

Yes
No

Irregular Heartbeat *

Yes
No

Kidney Problems *

Yes
No

Leukemia *

Yes
No

Liver Disease *

Yes
No

Low Blood Pressure *

Yes
No

Lung Disease *

Yes
No

Mitral Valve Prolapse *

Yes
No

Osteoporosis *

Yes
No

Pain in Jaw Joints *

Yes
No

Parathyroid Disease *

Yes
No

Psychiatric Care *

Yes
No

Radiation Treatments *

Yes
No

Recent Weight Loss *

Yes
No

Renal Dialysis *

Yes
No

Rheumatic Fever *

Yes
No

Rheumatism *

Yes
No

Scarlet Fever *

Yes
No

Shingles *

Yes
No

Sickle Cell Disease *

Yes
No

Sinus Trouble *

Yes
No

Spina Bifida *

Yes
No

Stomach/Intestinal Disease *

Yes
No

Stroke *

Yes
No

Swelling of Limbs *

Yes
No

Thyroid Disease *

Yes
No

Tonsillitis *

Yes
No

Tuberculosis *

Yes
No

Tumors or Growths *

Yes
No

Ulcers *

Yes
No

Venereal Disease *

Yes
No

Yellow Jaundice *

Yes
No

Have you ever had any serious illness not listed in this form? *

Yes
No

Comments

Disclaimer

To the best of my knowledge, the questions on this form has been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the Choice Dental office of any changes in medical status. *

Please check this box if you agree to this statements

Date *

Name

Choice Dental Limited.

We are a team of dentists, hygienists and nurses.

0811 113 1200 | 0700DENTIST (0700 336 8478)

office@choicedentalng.com

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