Online Medical History – HughRich Dental

Patient's Name *

First

Last

Person Responsible for the Account/Next of Kin: Name and Contact Information

Email *

Mobile Number

Date of Birth

Address

Postal Address (If same as above then leave blank)

Medical Conditions

Other/Explain if any ticked boxes

List of Medications

Dental Concerns

Other/Explain if any ticked boxes

same as to

I hereby consent for diagnostic aids (photographs, X-rays, etc.) to be taken and for dental treatment to be performed on me/my child. I understand that payment may be required on the day of treatment (Yes/No)