Patient Registration

We offer all new and existing patients at Upton Park Dentalcare a warm welcome. We are delighted that you have selected our practice to provide your dental care. At our practice, we consistently endeavor to deliver an outstanding service to our patients.

In order to help us meet your dental care requirements it is essential that we have accurate and up to date information regarding your health. This will help us identify any conditions that may be relevant to your dental health or which could have an impact on how treatment is carried out. So that we can provide the best care for you, please can you complete this form regarding your medical and dental health.

Thank you,

Upton Park Dentalcare Team

Upton Park Dentalcare Confidential Medical History

Date of Birth

Past Dentalcare

Have you seen dentist in the last 6 months?

Have you seen a hygienist in the last 6 months?

Are you currently registered with a Dental Practice?

Have you left another practice to come here?

COVID-19 related questions

Do you have a fever?

Do you have flu-like symptoms?

Do you have a continuous cough?


Are you currently taking any medications?


Do you smoke of use nicotine products?

Do you chew tobacco, pan, gutka, supari?

Do you consume alcohol?

Do you have high sugar frequency / intake?

Do you have high acidic food or drink frequency / intake?

Do you take recreational or illegal drugs?


Have you ever suffered with Rheumatic Fever?

Do you have high blood pressure or hypertension?

Have you ever undergone heart surgery?

Do you have high sugar frequency / intake?

Do you wear a pacemaker?

Do you have a heart murmur?

Do you have angina?

Have you ever suffered with thrombosis?

Have you ever suffered a heart attack?

Do you have any other heart conditions?


Do you have Hepatitis A, B or C?

Do you have HIV or AIDS?

Do you have anaemia?

Do you have sickle cell disease?

Do you have haemophilia?

Do you have blood-clotting problems?

Ever had blood refused by a blood transfusion service?

Have you ever had an abnormal blood test result?

Do you have any other blood conditions?


Do you have an allergy to penicillin?

Are you allergic to aspirin?

Do you have an allergy to any medicines?

Do you suffer with hay fever?

Do you have Eczema?

Do you have an allergy to latex?

Are you allergic to any foods?

Do you have an allergy to plants?

Do you have an allergy to anti-tetanus serum?

Have you ever had a bad reaction to local anaesthetic?

Have you ever had a bad reaction to general anaesthetic?

Do you have any other allergy?


Do you suffer from asthma?

Do you have any form of COPD?

Have you ever had pleurisy or pneumonia?

Do you have cystic fibrosis?

Have you ever had any surgery to your chest?

Do you have any other chest condition?

Other Conditions

Have you ever had any liver disease (e.g. jaundice)?

Have you ever had any kidney disease?

Do you (or a blood relative) suffer with diabetes?

Do you suffer with acid reflux?

Have you ever had an eating disorder?

Do you suffer from epilepsy?

Do you have Arthritis?

Do you have bone or joint disease?

Do you have an artificial joint?

Do you suffer with fainting attacks, giddiness or blackouts?

Have you ever had Brain Surgery?

Have you ever had Growth hormone treatment before the mid 1980s?

Have you ever suffered with cancer?

Any other (past or current) serious or infectious disease?

Has a close relative (parent, sibling, child, grandparent or grandchild) with Creutzfeldt jakob Disease?


Are you pregnant or possibly pregnant?

Are you currently breastfeeding?

Do you require antibiotic cover?

Have you taken steroids in the last 2 years?

Do you take bisphosphonates?

Do you have a hiatus hernia?

Do you have problems being reclined?

Are you currently under the treatment of a doctor?

Do you carry a warning card?

Do you bleed or bruise excessively following surgery?

Do you suffer with a phobia or fear of the dentist?

Other treatment that has needed you to be hospitalised?

Anything else your dentist should know?

Areas of concern

Cosmetic Dentistry


We process personal data for the purposes of providing optimum healthcare, sending important updates to you, providing you with news about treatments and what is happening at the practice and informing you about our services and promotions. You can withdraw your consents at any time by calling 020 8552 9293.

The practice can contact me by:
I would like to receive important practice announcements and updates in the practice newsletter
I would like to receive details of practice services and promotions
I would like to receive practice survey and feedback requests
Completed by
Full Name

Your personal information will never be passed to third parties unless we are making a professional referral for you. If we have your consent for referral to another health care provider we will send them just the information that they need to provide the necessary assessment, tests or treatments. For further details about how we process your personal information please see our Privacy Notice at the practice or contact us on 020 8552 9293 to request a copy of it.