Medical History Form

Due to the COVID-19 pandemic, the safety of our team and our valued patients is our main priority. In addition to our increased infection control procedures, we have therefore also had to introduce some new ways of working - one of which is asking all of our new patients to complete the below Medical History Form before you visit us for your appointment.

Thank you in advance for your co-operation on this, and for taking the time to help us keep everyone protected. We look forward to seeing you soon!

1. Patient Details

2. How did you hear about us?

3. What are your main concerns with your smile?

4. Medical History

Please ensure you answer all of the questions in the below section:

5. Additional details
Medical Doctor
General Dental Practitioner (your normal dentist)

6. Please let us know your communication preferences
What we do with your data

GDPR guidelines require us to ensure that we keep your personal data safe and handle it responsibly. Here at Just Orthodontics we take these guidelines very seriously and have strict policies in place for this. We only keep information that is directly relevant to you and to your care. All data is stored securely in a digital format. We keep treatment records indefinitely - as you, or we, may need to refer back to them in the future. You are entitled to request copies of the records we hold about you and your treatment. You are also entitled to request that we make corrections to any errors in the data that we hold about you.

7. Sign off

By clicking 'send' you are consenting to us replying, and storing your details. (see our privacy policy).

Boutique Whitening
© Copyright 2024 Just Orthodontics | Sitemap | Website Privacy Policy | Patient Privacy Policy | Patient Complaints