Get to know me

Learning, physical or mental difficulties? Help us to learn more about you, so that we can make reasonable adjustments to enhance our care.

Dental Practice I will be attending *

PERSONAL information

Full Name *

My Name

Date of Birth *

Telephone *

Email *

Other people I would like you to contact about my treatment and care

Full Name

Relationship to patient

Contact number

MEDICAL history

My medication & medical history *

COMMUNICATION

How I would like you to communicate with me

How I communicate

How I experience and communicate pain

ABOUT yourself

Things that I struggle with that causes me distress

Ways to help me avoid distress

Sensory needs

Other things you should know about me

Thank-you.