Medical History - The Holland Park Dentist

Please ensure you have completed this Medical History form prior to your appointment.

This is a confidential form and will be stored in accordance with the General Data Protection Regulation 2018.

This Medical History must be updated every year or sooner if anything changes

Confidential Medical History Form

All personal data that you provide will be processed, stored and shared in accordance with the General Data Protection Regulation 2018.

Personnel Details

Title (Mr, Mrs, Miss, Ms or other)

First Name

Surname

Gender

Male

Female

Other

Date of Birth

Address

Post Code

Home Telephone

Work Telephone

Mobile Telephone

Occupation

GP Surgery Information

Name

Address

Telephone

Emergency Contact

Name

Relationship to You

Telephone

Dental History

When did you last visit the dentist?

Do you have dental pain or a problem at present?

Do you become anxious or uncomfortable from dental treatment?

Are you interested in the following types of dental treatment?

Smile Makeover

Fillers or Botox

Implants

Veneers

Teeth Whitening

Other

Are you currently? No Yes Give Details

Receiving treatment from a doctor, hospital or clinic?

Carrying a Medical Warning Card?

Pregnant or Possibly Pregnant?

Due Date:

Taking any prescribed medication?

Have you ever had? No Yes Give Details

Allergic reaction to medication (e.g., penicillin)?

Substances (e.g., rubber / latex) or foods?

Asthma, Bronchitis, emphysema or another chest condition?

Fainting attacks, Giddiness, blackouts or epilepsy?

Diabetes?

Does anyone in your family have diabetes?

Bone or joint disease, or taken medicine that affects the bones?

Any other serious illness or infectious disease (e.g., HIV or Hepatitis)?

Blood refused by the Blood Transfusion Service?

A bad reaction to local or general anaesthetic?

Treatment that required to be in hospital?

Bruising or persistent bleeding following injury?

Tooth extraction or surgery?

Liver or kidney disease (e.g., jaundice or hepatitis)?

High blood pressure?

Heart problems, heart surgery, stroke, angina or a pacemakerfitted?

Tobacco and Alcohol No Yes / In the Past

Do you smoke?

Do you chew tobacco, pan gutka or supari?

Do you drink alcohol?

A unit is half a pint of beer, a single measure of spirits or a small glass of wine.

How did you hear about the practice?

I certify that I have read and understood the questionnaire and the answers I have given are, to the best of my knowledge, true and accurate.

I consent to being contacted regarding my treatment. I understand that I may withdrew my consent at any time.

Signature

Date

What’s next?

Have you completed all of the e-Documents that are required prior to your appointment?

Please refer to your Pre-Arrival email sent to you from the practice, please check your spam and junk folders too.

Get in touch

Testimonials

“After calling up around 20-30 dental practices none were able to take me in as a new patient, due to Covid. till I called Smile Style, Sara (the receptionist) was…”

Izzy

“Dr Aron Balkin is a truly fantastic Dentist. From the moment you step into the practise, you know that you are being looked after by professionals. His warm nature and…”

Joel M.

“Extremely professional, very polite and friendly atmosphere. Highly recommend the practice for the entire family. I have started taking my toddler there so as to have regular check up and…”

Evgenia K.

“Yesterday I had my first dental cleaning at this practice. What can I say more than amazing!!! The hygienist has been kind, friendly, really good (painless) and professional at the…”

Nick A

“I've been going to the dentist and hygienist here for almost 25 years even though I no longer live or work in the area. I've always received excellent advice and…”

Marianne T.

“I had my first visit to Smile Style this morning and had a great experience - I look forward to going back in 6 months. The hygienist and the dentist…”

Olivia M.

Rachel May

16:09 09 Jul 21

Dr Faro is the best dentist I have ever had. Highly recommend, wouldn’t go anywhere else!

17:14 11 Dec 20

After calling up around 20-30 dental practices none were able to take me in as a new patient, due to Covid. till I called Smile Style, Sara (the receptionist) was very kind to have a word with the doctor and was seeing on the same day, the Doctor was very gentle since I have sore gums, I couldn’t be any happier! As I expected to be in a lot of pain during the treatment. Excellent service throughout the visit. 10/10 for me

Joel Marks

13:29 25 Sep 19

Dr Aron Balkin is a truly fantastic Dentist. From the moment you step into the practise, you know that you are being looked after by professionals. His warm nature and level of care are excellent. Would recommend to anyone who needs a local dentist.

Olivia Mackasey

18:53 23 Oct 17

I had my first visit to Smile Style this morning and had a great experience - I look forward to going back in 6 months. The hygienist and the dentist were both incredibly friendly, professional, and punctual. Only great things to share thus far about Smile Style!

Simon Beaufoy

15:02 05 May 17

Aron has been keeping my teeth in good order for over twenty years. His practice used to be called the Gentle Dentist- which sums up the experience perfectly. He is expert, fast and very gentle. I can't recommend him highly enough.

tim S

09:45 22 Mar 17

Dr. Aron Balkin and his team are fantastic! i had an issue that i wanted immediate attention. i called in the afternoon and i was given an appointment the following day. i was most impressed with thoroughness in which Dr. Aron checked out the issue. in addition to his own assessment, he contacted 2 specialist who concurred with his assessment. luckily the issue was benign.My wife and i have both use Smile Style. On every occasion, our expectations were exceeded. Super friendly and excellent service!

sheryl faulkner

17:07 09 Feb 17

Aron is an amazing dentist, I suffered from extreme anxiety due to having awful experiences with previous dentists.Aron was patient with me and made me feel relaxed and ALL of my extensive dental work was carried out in a professional way and was virtually painless.He made me feel confident and explained everything he was doing every step of the way. I cannot express how happy I am with his service and his assistant and hygienist are fantastic.I am no longer afraid of going to the dentist and it's all due to Aron and his wonderful team, I cannot praise them enough.

Philip Mckinlay

01:15 24 Jan 17

I found Aron and his team some of the most professional I have ever dealt with. I had a cracked tooth so was grateful that Aron's receptionist booked me in at such short notice and that Aron put the matter to rest immediately. Aron is very friendly, professional and personable, a must for any dentist. If you want a great dentist experience go and see Aron and his team as I certainly will be.