Anna House Dental Clinic

Please note NHS spaces are limited and subject to availability.

LANGUAGE

English 0208 88 55 777 | Polish 0208 88 55 355 | Spanish & Portuguese 0208 80 80 080

English 0208 88 55 777
Polish 0208 88 55 355
Spanish & Portuguese 0208 80 80 080

Home
About Us
- About The Practice
- Meet The Team
Treatments
General Dentistry

New Patients

Oral Hygiene

Fissure Sealants

Gum Disease

Root Canal

Dentures

White Fillings

Children’s Dentistry

Nervous Patients

Cosmetic Dentistry

Cosmetic Bonding

Dental Implants

Porcelain Veneers

Crowns & Bridges

Inlays & Onlays

Teeth Whitening

Smile Makeovers

Teeth Straightening

Facial Aesthetics

Lines & Wrinkles

Dermal Fillers

Juvederm
Prices
- Private Fees
- NHS Charges
Contact Us

Slide 1

Medical History

Please fill in our Confidential Medical History Form before you attend the practice.

Fill in your details
Submit the form
We will contact you to book an appointment

Online Form

Slide 1

Medical History

Please fill in our Confidential Medical History Form before you attend the practice.

Fill in your details
Submit the form
We will contact you to book an appointment

Online Form

Medical History Form

Please update your dentist as soon as possible if anything below changes – you will be asked to complete a new form at least every 12 months.

Name *

Paragraph Text *

Email *

Phone *

Date of Birth *

Practice reminders *

SMS
EMAIL
LETTER
OPT OUT

Special offers & promotions *

SMS
EMAIL
LETTER
OPT OUT

Practice updates *

SMS
EMAIL
LETTER
OPT OUT

How did you hear about this practice? *

Website
Family or friend
Local area
Magazine
Radio
NHS choices

Are you seeing a doctor for any reason? *

Do you have liver/ kidney disease? *

Do you have diabetes? *

Are you asthmatic? *

Do you carry any warning cards? *

Do you have a high sugar/acid intake? *

Do you have nny allergies? (please list below) *

Have you had brain surgery? *

Do you have high or low blood pressure? *

Do you have creutzfeldt–Jakob disease? *

Do you suffer with angina? *

Do your gums bleed? *

Have you had a stroke? *

Are you pregnant? *

Have you had heart surgery? *

Do you HIV/hepatitis? *

Is bleeding normal after cutting or tooth removal? *

Do you problems with local or general anaesthetic? *

Do you smoke? If yes how many (please list below) *

Do you drink alcohol? If yes how many units (please list below) *

Are you taking any medications? (please list below) *

Any other illnesses not listed above *

GP Address: *

GP Phone *

Please note down any medications you are currently taking

Please list any allergies

Signature *

I agree to your privacy policy

Getting in touch

Call the practice today on one of the following numbers. Alternatively please use the Enquiry Form below.

English

0208 8855 777

Polish

0208 88 55 355

Spanish & Portuguese

0208 80 80 080

To keep up to date with all that’s happening at Anna House you can also follow us on social media.

Facebook

Instagram

ENQUIRY FORM

To get in touch please complete the fields below and we’ll get back to you as soon as possible.

Please note NHS spaces are limited and subject to availability.

Name *

First

Last

Email *

Phone *

How did you hear about us?

Message

I agree to your privacy policy *

I have read and agree to your privacy policy

Marketing

Yes, I would like to receive communications from Anna House Dental Clinic about products and services that might be of interest to me.

How to find us

Telephone Numbers

0208 88 55 777

0208 88 55 355

0208 80 80 080

0208 80 80 080

Address

Anna House Dental Clinic
214-218 High Road
Tottenham
London N15 4NP

Email Us

Facebook

Instagram

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General Dentistry

Cosmetic Dentistry

Facial Aesthetics

Medical History Form