Pre-surgical Health Check — PerioCARE

Pre-surgical Health Check

Patient Information (Mandatory)

First Name

Last Name

Email

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Relationship

Phone

(###)

###

####

Doctors Caring for You

Name of your family doctor

Name of the practice / Medical centre

Specialist (e.g. Cardiologist for chest pain)

Have you had any allergies or side effects from medications, food, plasters or insects? Please list them.

List all your current medications

Including asthma or nasal sprays and over-the-counter treatments such as pain killers, antihistamines and antacids and any that you have taken in the past 6 months.

Your most recent visit to the doctor was

Is there anything that I should be aware of that may affect your procedure and after care visits?

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