Medical History Questionnaire

Personal Information

Patient Full Name *

Date of Birth *

Residential Address *

Contact Phone Number *

GP (Doctor) Name & Clinic

Scheme & Recall Consents

I consent to Portlaoise Dental checking my PPS No. to verify eligibility under the PRSI Dental Benefit Scheme (1 Free Annual Exam + Subsidised Hygiene Scale & Polish).

I consent to receive friendly reminder messages (SMS text or phone call) for my routine check-ups and hygiene appointments.

General Medical History

How is your general health?

Do you smoke or use tobacco?

Do you have any known allergies (e.g. Penicillin, Latex, Local Anaesthetics)?

Current prescription or over-the-counter medications:

Excessive bleeding or easy bruising?

Women: Pregnant or nursing?

Medical Conditions Checklist

Please check any condition that you currently have or have had in the past:

Heart Disease / DisorderStrokeBronchitisKidney DiseaseEpilepsyHepatitis B / CHeart SurgeryDiabetesLiver DiseaseArthritisRadiation Treatment to Head or NeckHIV / AIDSRheumatic FeverAsthmaCancerArtificial Joints (Hip / Knee)Shortness of BreathHigh Blood Pressure

Electronic Signature (Full Legal Name) *

Date *

I certify that I have read and understand the questions above, and have accurately answered each question to the best of my knowledge.

Appointment Request

Schedule Your Dental Visit

Fill in your details below or call our reception directly at 0578621832.

Full Name *

Phone Number *

Email Address *

Treatment Needed

Preferred Date

Check my eligibility under PRSI Dental Scheme

Notes or Concerns (Optional)

Our receptionist Collette will call or email you to confirm the exact appointment slot.

✓

Request Received!

Thank you for contacting Portlaoise Dental. Our team will review your preferred date and call you to confirm your booking.

Personal Information

Scheme & Recall Consents

General Medical History

Medical Conditions Checklist

Questionnaire Successfully Submitted!

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