We take our patients' health seriously so please give as much information as possible for your child. The Save button at the bottom allows you complete the form later. *The asterisk questions are compulsory.
Due to additional precautions resulting from the COVID-19 pandemic, please submit this completed form 2 days before your appointment.
This form data will be securely retained. We will send you a link to your existing data prior to each appointment. You will only need to update any areas of the form that have changed when you next attend.
Please note that all treatment carried out at Bow Lane Dental Group is photographically and occasionally video documented as part of your clinical record. As well as being a necessary part of your clinical record, these images may be used anonymously for the purposes of teaching, conference presentation, website, articles or promotional material, in the UK. We are bound by current General Data Protection Regulation (GDPR) 2018. (Please see Bow Lane Dental Groups current Terms and Conditions.)
Consent for use of all clinical data held by Bow Lane Dental Group:
I consent to my clinical images and data being shared within the practice for the purposes of clinical care and with dental or medical colleagues outside the practice such as anaesthetists, dental or medical colleagues, dental laboratories and other third parties directly involved with or advising on my clinical care.