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Medical History Form

Confidential Medical History

Due to additional precautions resulting from the COVID-19 pandemic, please submit this completed form at least 2 days before your appointment.

Personal details and contact information

Please list all the medicines or drugs (prescribed, over the counter or self medication) you take on a regular basis (including contraceptive pills, recreational drugs). If possible, please include dosages and frequency.

Dental Questionnaire

GDPR and consent

Please read carefully and indicate consent as appropriate

Please note that all treatment carried out at Thurloe Street Dental is photographically and occasionally video documented as part of your clinical record. As well as being a necessary part of your clinical record, these images may be used anonymously for the purposes of teaching, conference presentation, website, articles or promotional material, in the UK. We are bound by current General Data Protection Regulation (GDPR) 2018.

Consent for use of all clinical data held by Thurloe Street Dental:

I consent to my clinical images and data being shared within the practice for the purposes of clinical care and with dental or medical colleagues outside the practice such as anaesthetists, dental or medical colleagues, dental laboratories and other third parties directly involved with or advising on my clinical care.

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