Become A Patient

Please take a moment to fill out the short questionnaire below with your details and we will be in touch shortly to let you know how to become a patient with Jordan Dental.

Are you carrying a medical warning card?

Yes No

Do you suffer from allergies to any medicines (eg penicillin) / substances (eg latex/rubber) or foods?

Yes No

Do you suffer from hay fever or eczema?

Yes No

Do you suffer from bronchitis / asthma or other chest conditions?

Yes No

Do you suffer from fainting attacks / giddiness / blackouts or epilepsy?

Yes No

Do you suffer from heart problems / angina / blood pressure problems or stroke?

Yes No

Have you ever had heart surgery?

Yes No

Are you diabetic ( or is anyone in your family) ?

Yes No

Do you suffer from arthritis?

Yes No

Do you suffer from any infectious diseases ( including HIV and Hepatitis) ?

Yes No

Have you ever had rheumatic fever or chorea?

Yes No

Have you ever had liver disease (eg jaundice / hepatitis) or kidney disease?

Yes No

Have you had any other serious illness?

Yes No

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

Yes No

Do you regularly drink more than 14 units of alcohol per week?

Yes No

Do you smoke any tobacco products?

Yes No

Your Name:

Your Email Address:

Your Contact Number:

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