Patient Medical History & Consent · Cumbria Dentist at Door

1. Patient Details

Full Name *

Please enter patient's full name

Date of Birth *

Please enter date of birth

NHS Number (if known)

Postcode

Address

Telephone

Mobile

Email

Please enter a valid email address

Preferred method of contact

Phone

Text

Email

2. Emergency Contact

Name

Relationship

Telephone

3. GP Details

GP Practice

Telephone

Address

4. Dentist Details (if registered)

Practice Name

Dentist

Telephone

5. Medical History

Have you ever had or do you currently suffer from any of the following?

Please provide details for any conditions checked:

Other significant medical condition details:

6. Allergies

Are you allergic to:

Penicillin

Latex

Local Anaesthetic

Aspirin

Chlorhexidine

Metals

Foods

Other

Please specify any allergies:

7. Current Medication

Please list all medicines including inhalers, blood thinners, insulin, osteoporosis medication and supplements.

Medication

Dose

Reason

8. Smoking & Alcohol

Do you smoke?

No

Yes

Do you vape?

No

Yes

Alcohol units per week

9. Dental History

Reason for today's visit

Date of last dental visit

Current dental issues

Current dental pain

Loose teeth

Bleeding gums

Sensitive teeth

Dentures

Full

Partial

None

Any previous problems with dental treatment?

10. Mobility & Home Visit Assessment

Wheelchair user

Bedbound

Requires hoist

Requires assistance to communicate

Carer present

Carer name (if applicable)

11. Capacity Assessment

Does the patient appear able to understand, retain and communicate decisions regarding treatment?

Yes

No

12. Consent for Examination & Treatment

The treatment will take place in their home and a suitable clean area will be made available.

Pets will be kept away during treatment where possible.

Children will be supervised.

Adequate lighting and access to electrical power (if required) will be available.

Treatment may be stopped if the environment is unsafe.

Understand that this is a domiciliary (home visit) service and give consent for a home visit.

Agree that if they require treatment beyond your scope, they will be referred to a dentist.

I am agree to pay the Exam and treatment fees.

I understand that failure to provide accurate information could affect / cancel treatment.

Patient Name

Date

Signature (type name to confirm)

13. Photography Consent

I consent to clinical photographs for:

Clinical records

Referral

Education (anonymised)

I do not consent

Signature (type name to confirm)

14. Data Protection (UK GDPR)

I understand that Cumbria Dental Care Limited will securely store and process my personal information for the purpose of providing dental care, complying with legal obligations and maintaining clinical records. I understand my rights regarding access, correction and confidentiality of my information.

Signature (type name to confirm)

Date

15. Clinician Declaration

Medical history reviewed

Risk assessment completed

Consent obtained

Treatment appropriate

Clinician Name

GDC Number

Signature

Date

Review

Medical history should be reviewed:

Every appointment

At least every 12 months

Any changes since last visit?