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 a treatment is carried out.

You have two options:

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

1. MANUAL FORM FILL-IN

Click here to download the MEDICAL HISTORY FORM.

2. ONLINE FORM FILL-IN

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 medical history Button at the bottom, all your details will be sent via email to Corn Market Dental in Wimborne and are completely confidential.

Medical History

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

Medical Q7 - Heart. Have you had any of these conditions?
Medical Q8 - Blood. Have you had any of these conditions?
Do you have any allergies?
Medical Q10 - Any Warnings?
Medical Q11 - Chest Conditions?
Medical Q12 - Other Conditions?

What Our Patient’s Say