Cosmetic Dentist Milton Keynes, UK - Brooklands Dental Clinic in Broughton, Milton Keynes UK

Cosmetic & General

Complete Smile Makeovers
Tooth Whitening
Porcelain Veneers
Crowns
Bridges
Cosmetic Fillings
Gum Line Correction
ClearStep
Wedding Smile Makeovers

Specialist Dentistry

Sedation Dentistry
Endodontics
Periodontics
Dental Implants
Prosthetics
Surgical Extractions

Restorative Dentistry

Preventive Dentistry
Dental Hygiene Visits

Aesthetic & Well-being

Anti-Wrinkle Treatments
Dermal Fillers
Weight Management
Life Skills Coaching

When coming in for your initial treatment, it is necessary to complete a Patient Medical History Form to help us highlight any special needs you may have.

Download the Patient Medical History Form in PDF format.
» Click here to download

General Details:

Title:

Full Name:

Date of Birth:

House/Flat Number:

Street:

Town / County:

Postcode:

Tel No. Home:

Mobile

Email:

Occupation:

Work No:

Referred by (if another patient please state name):

When did you last visit:

- The Dentist

- The Hygienist

To help us provide the best possible treatment, dependant upon your needs, we would appreciate if you could indicate below which treatments interest you?

Treatment of Pain Only
Regular Hygiene for maintenanceof healthy gums
Cosmetic Treatment
Whitening of your teeth
Implants (replacement of teeth)
White fillings
Facial Aesthetics
Other

How would you prefer to be contacted by us?

Recall examination:

Confirmation of appointment:

Medical History Update:

Do you have a history of, or ever suffered from the following? (Please tick only those that apply)

Heart	Arthritis	Heart Surgery	Pacemaker
Rheumatic Fever	Kidney	Liver Disease	Chest Problem
Hayfever	Asthma	Diabetes	Anaemia
Hepatitis	HIV	Epilepsy	High/Low BP
Giddiness	Thyroid	Allergies	Other

For other and/or allergies, please give details

Do you smoke?

Yes No

If so how many per day?

Do you drink Alcohol?

Yes No

If so how many units per day?

Have you ever had a bad reaction to a general or local anaesthetic?

Yes No

Are you under the care of a doctor at present?

If yes, please give details

Yes No

Are you currently taking medication?

If yes, please give details

Yes No

If you are pregnant, please give expected birth date:

If you are allergic to any drugs, please give name of drug/s

Details of person to contact in an emergency:

Name:

Phone:

Medical Doctors Name:

Phone (If known):

Security:

Confirmation code: *

Please enter the black letters exactly as they appear in the image below, into the box above.

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Our team of Dentists & Specialists are happy to answer any questions you may have about any of our dental treatments.

We invite you to take a tour of our exquiste state-of-the-art dental & specialist clinic online.

Mr and Mrs Freeman pictured, commented

"having been patients at Brooklands Dental Clinic since it opened in March 2007, we are thrilled that the excellent service and treatment have been recognised and look forward to them having a long and happy future"

Mr and Mrs Freeman



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