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INTAKE


View of Client Intake
1
Preferred Pronouns:
FirstName
LastName
Address:
Date of Birth:
Mobile Number:
Occupation:
Email Address:
Doctor Name:
Practice Name
Where did you hear about Mint Dental Hygiene?
How many units of alcohol do you consume on average per week? 1/2 pint beer/lager = 1 unit 1 small glass wine = 1 unit
Last Dental Visit?
Are you Pregnant?
Are your teeth sensitive?
Do your gums bleed?
Would you like whiter teeth?
Are you aware of bad breath?
Do you have a pacemaker, heart murmur, history of Rheumatic fever, angina, had any form of heart surgery or any other heart problem?
Have you had Jaundice, liver, kidney disease or hepatitis?
Please tick if you have any blood born viruses including H.I.V. Hep C etc
Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
Have you had a bad reaction to a local anaesthetic?
Are you taking any medicines from your doctor? (Tablets, creams, ointments, injection, contraceptive pill, other)
Have you taken steroids in the last 2 years?
Have you had a joint replacement?
Do you carry a warning card?
Do you have epilepsey?
Are you diabetic?
Have you ever had Chemo or Radiotherapy?
Do you have any other medical condition not mentioned?
Are you a smoker or vape?
Leaving the surgery, any non-payment of treatments will incur additional fees and any cost related to debt collection. By signing this two page New Patient Form you accept Mint Dental Hygiene terms and conditions and agree that you have provided correct information to us.
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I agree to the above statement.
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Client Intake
1
EFIRST
ELAST
Preferred Pronouns:
FirstName
LastName
Address:
Date of Birth:
Mobile Number:
Email Address:
Occupation:
Doctor Name:
Practice Name
Where did you hear about Mint Dental Hygiene?
Are your teeth sensitive?
Do your gums bleed?
Would you like whiter teeth?
Are you aware of bad breath?
Do you have a pacemaker, heart murmur, history of Rheumatic fever, angina, had any form of heart surgery or any other heart problem?
Have you had Jaundice, liver, kidney disease or hepatitis?
Please tick if you have any blood born viruses including H.I.V. Hep C etc
Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
Have you had a bad reaction to a local anaesthetic?
Are you taking any medicines from your doctor? (Tablets, creams, ointments, injection, contraceptive pill, other)
Have you taken steroids in the last 2 years?
Have you had a joint replacement?
Do you carry a warning card?
Are you diabetic?
Do you have epilepsey?
Have you ever had Chemo or Radiotherapy?
Do you have any other medical condition not mentioned?
Are you a smoker or vape?
How many units of alcohol do you consume on average per week? 1/2 pint beer/lager = 1 unit 1 small glass wine = 1 unit
Are you Pregnant?
Last Dental Visit?
1
Nova
Edgcombe
Nova
Edgcombe
65b Alexander Avenue, Torbay
4/4/1975
0212306517
dental hygienist
no
no
no
no
no
6/12/2023
2
Brian
DeGregory
Brian
DeGregory
5/27 Wallace St
8/1/1980
021487189
Consultant
Alison
Herne Bay Medical
Nova
yes
no
yes
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
0
no
3/15/2023
3
Brian
DeGregory
Brian
DeGregory
5/27 Wallace St
8/1/1980
021487189
Consultant
Alison
Herne Bay Medical
Nova
yes
no
yes
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
0
no
3/15/2023
4
Brian
DeGregory
Brian
DeGregory
5/27 Wallace St
8/1/1980
021487189
Consultant
Alison
Herne Bay Medical
Nova
yes
no
yes
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
0
no
3/15/2023
There are no rows in this table
yesnoOptions
0
Are your teeth sensitive?
1
yes
2
no
There are no rows in this table

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