Whiterose Clinic Medical Form

Medical History and Treatment Request Form

Your Name:*
Your Email:*
Date Of Birth:*
Male or Female?:
Male Female
Your Contact Number:*
Do you have any medical problems? If so, then please list.: *
If you are nervous of dentistry do you want relaxation procedures for which there is a fee: 
Yes No
Are you seeing at Doctor at present?: 
Yes No*
Do you have any heart problems?: 
Yes No*
Do you smoke?: 
Yes No*
How Many per Day?: 
Do you have any allergies?: 
Yes No*
Do you have any communicable diseases? (e.g. HIV, Hepatitis): *
Do you have Diabetes? : 
Yes No*
Do you have Epilepsy?: 
Yes No*
Do you have any problems with Bleeding?: 
Yes No*
Is it possible you may be pregnant?: 
Yes No*
Are you taking any medication? If so please give details: *
Have you ever been notified that you are at increased risk of CJD on VCJD for public health purposes?: 
Yes No*
Do you or have you suffered from stress, anxiety or depression (give details): 
Yes No*
 What Treatment are you requesting? :
Tooth Whitening
White Inlays
Replacing gap with a bridge
Replacing gap with an implant
I am a smoker
Getting rid of bad teeth and replace with implants
Getting rid of loose teeth
I want implants that are fixed into my mouth and I don’t have to remove
I want implants that tighten a denture that I remove and clean
Hygienist care of gums and for fresh breath
Removal of stains calculus
Gum surgery/treatment
Aesthetics/changing the appearance of my teeth
Sore tooth that needs extracted (surgical fee if oral surgery needed)
Wisdom teeth that need removed
I need a cyst removed
Swelling or abscess
Worried about pathology (sores) swellings in the mouth
Colour change or strange appearance in mouth
I don’t like appearance of high lip and gummy smile
Routine check-up (required if attending hygienist)
Ozone therapy for gums if swollen bleeding infected
I need my teeth straightened (orthodontics) we refer for this
X-ray of jaws (additional fee if CT scan is required) to help with planning
Dentures whole mouth or part denture
Dentures with valves to help tighten up
Removal of infected Implant
I need more lip support
I need a loose or broken crown/bridge replaced
I only want a second opinion*
What do you not like about your teeth?:

How did you hear about us?

Yellow pages
Our Website
Patient Referred


Note: we are a mercury free clinic and do not provide these. A new patient discussion usually involves an OPG x-ray £45.00, examination £20.00 and photographs £00.50. If a CT scan is needed for one arch this is an extra £90.00, other investigations may be necessary.

Consent for Oral Surgery: Before undergoing surgical treatment you need to give our consent to the procedure. Oral surgery like any operation, carries the risk of possible complications. These include swelling, jaw stiffness, bruising, pain and possible permanent numbness in areas of your mouth. This is however a rare occurrence and we will explain to you the possible risks involved in your treatment. Heavily filled/ Decayed teeth/Poor Home Care which can give bleeding gums, recession, sensitivity may cause nerve damage resulting in additional treatment at an extra cost after crowning or filling. Apicectomy on root filled teeth has a separate fee. Please ask the surgeon if you have any queries. While we make every effort to prevent the above complications you should be aware of them.

Procedure & Warnings: For Patients to receive restorative work at this practice you should comply with a maintenance of dental work i.e. attend for oral health checks with Dr McKenna every 6 months, with the hygienist every 3 months and have continuous home dental care. Practice patients after 2 years non-attendance you are not considered a patient of the practice and guarantees are void. I agree to settle all fees due when requested. There is a fee for non-attendance without 2 working days notice. Items involving laboratory fees are payable in advance. Finance must be settled before Dental work is inserted.


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