Dental & Implant Centre in Tonbridge, Kent

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Medical History Form

You can complete a medical history form by completing the online form below. However, if you would prefer you can click on the below link to download a printable form, which you can then send back to us via email, or post: River Lawn Dental & Implant Centre, 1 River Lawn Road, Tonbridge, Kent, TN91EP.

Click here to download a printable PDF version of our medical history form. Once filled in, please return to us via fax or post.

Patient Details

Patient Name:
Date Of Birth:
Occupation:
Patient Email:
Contact Number:
Patient Address:
Postcode:
How did you hear of us?
Your GP's Details:

Do You Have Private Dental Insurance:

Are You Exempt For Payment Of Dental Fees?:

Further Information - Please Complete As Appropriate

Are you currently pregnant?

Are you currently receiving treatment from a doctor, hospital or clinic?

Have you had treatment that required you to stay in hospital & has this involved surgery?

Do you carry a medical warning card or bracelet?

Are you currently taking any prescribed medicines (e.g. tablets, ointments or inhalers including contraceptives and hormone replacement therapy)?

Do you suffer from any allergies to medicines (e.g. penicillin), substances (e.g. latex or rubber) or foods?

Do you suffer from hay fever or eczema?

Do you suffer from bronchitis, asthma or other chest conditions?

Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?

Do you suffer from heart problems, angina, blood pressure problems or stroke?

Are you diabetic (or is anyone in your family?)

Do you suffer from arthritis?

Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?

Do you suffer from any infectious disease (including HIV & hepatitis)

Have you ever had rheumatic fever or chores?

Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease?

Have you (or anyone in your family) ever have/had any type of cancer?

Have you ever had any other serious illness

Have you ever had blood refused by the Blood Transfusion Service?

Have you ever had a reaction to general or local anesthetic?

Have you ever had a joint replacement or any other implant?

Have you ever had brain surgery?

Do you have any close relative (parent, sibling, child, grandparent or grandchild) with Creutzfeldt jakob disease?

If you are female, do you regularly drink more than 14 units of alcohol per week?

If you are male, do you regularly drink more than 21 units of alcohol per week?

Do you smoke, or have you ever smoked? Please state how much and when.

Do you chew tobacco, pan, gutkha or supari now (or did you in the past)?

Is there any other information that your dentist might need to know about? Such as aspirin etc.

Do you suffer from cold sores?

Have you ever had heart surgery, or been fitter with a pace maker?

Dental Implants
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We have been successfully placing and restoring dental implants for many years, enabling patients to smile with confidence.
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Cosmetic Dentistry
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Today, how you look is more a matter of choice than genes and it is no different when considering your choice of smile.
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Orthodontics
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At River Lawn Dental and Implant Centre we offer a wide range of Orthodontic treatments, providing treatments to people of all ages.
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Teeth Whitening
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Whitening is a process where the tooth discolouration is 'whitened' to a lighter shade. It removes the staining agent through chemical means.
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Dental Sedation
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As dentists with an interest in treating dental phobics, it is essential that we treat you, the patient as an individual and customise your treatment to your specific needs.
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Facial Aesthetics
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At River Lawn Dental and Implant Centre we offer a range of anti-wrinkle and facial rejuvenation treatments.
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