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Medical History Form

It is important for your dentist to have your medical history up to date and understand your health needs before any examination or treatment is carried out.

You have two options:

  1. You can either fill in the Medical History Online below OR
  2. Download the Medical History form, print it out, fill it in and then hand it in at reception.

1. MANUAL FORM FILL-IN

Click here to download the MEDICAL HISTORY FORM.

2. ONLINE FORM FILL-IN

Please fill in as many details as you can.  Fields which have this symbol * need to be filled in.

 Please note that when you click the SUBMIT Button at the bottom, all your details will be sent via email to Michael Shipway & Associates Dental Practice in Cheltenham and are completely confidential.

If you are a totally new patient, please click here to fill in the FULL NEW PATIENT FORM.