Patient Medical History Form
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Periodontist, Endodonist) Have you had your wisdom teeth removed Please tick below which oral hygiene aids you use Toothbrush Electric Toothbrush Interdental Brushes Mouthwash Dental Floss Other How do you feel about having dental treatment at this surgery today Please tick Extremely Nervous Moderately Nervous Mild case of nerves Relaxed and Confident Do you want your treatment at this surgery to involve: Yes No Examination of your teeth and mouth Relief of pain today only, no further treatment or advice Repair of teeth as required Regular follow up, cleaning and preventative services Consultation with you as to your treatment needs Whom should be thank for recommending you to our surgery What are your greatest concerns and needs for your dental treament CONSENT FOR SERVICES • • • • I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees associated with these procedures..
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