Dundee Dental Hospital
Undergraduate Student Clinic
Surname
Address including post code
Confidential medical history
Prior to any dental treatment being undertaken it is important we obtain a detailed medical history from you.
This is for your own protection as your medical history may have a bearing on the dental treatment we carry out.
Before a medical history is taken, we need you to answer a few preliminary questions:
Your dentist’s name and address Your doctor’s name and address
First names
Have you been resident in the UK for the past 12 months?
Telephone number
Title Date of birth (dd/mm/yyyy)
Sex
Occupation
Birth surname
Male Female
Have you attended the Dental Hospital previously?
Yes No
Approximate date of attendance (if yes)
Your height
Your current weight
Yes
Are you currently pregnant?
Have you visited your own doctor
in the last six months?
Have you been seen by a Hospital
Specialist (outwith the Dental
Hospital) in the last year?
Is there any other clinic attendance
you wish to discuss in confidence?
No Further details
Signature (type your full name for application by email)
Myself
Relationship to patient:
Parent
Other
Yes No
Date
I have read, and agree to, the terms and
conditions on page 2
Return by email: email your completed form to Tay.HealthRecordsReferralsDDH@nhs.scot
or by post to: Referrals Team, Dundee Dental Hospital, Park Place, Dundee, DD1 4HR
