Medical History Form Online

It is important for your dentist to have your medical history up to date and understand your health needs before any examination or atreatment is carried out.

You have two options:

  1. You can either fill in the Medical History Online below OR
  2. Download the Medical History form, print it out, fill it in and then hand it in at reception.


Click here to download the MEDICAL HISTORY FORM.


Please fill in as many details as you can.  Fields which have this symbol * need to be filled in.

 Please note that when you click the SUBMIT Button at the bottom, all your details will be sent via email to Corn Market Dental Practice in Wimborne and are completely confidential.

If you are a totally new patient, please click here to fill in the FULL NEW PATIENT FORM.

Medical History Form

Medical History

Units of alcohol

1pint = 3units,  Wine 175ml = 2 units,   Alcopop 1.4 units,   single spirit = 1 unit,   Bottle wine = 10 units .

By submitting this enquiry form, Corn Market Dental will securely collect your details. Please read our Privacy Policy on how we protect and manage your submitted data. You will be able to ask us for details of the personal data we hold on you, or ask us to delete it. We will never share your details with a third party.

* Required

If your form has been successful you will get a Thank You message on the screen, otherwise scroll back up and make sure you have entered all the required fields.