Welcome to 42

Some people can feel nervous about visiting the dentist. At 42 The Dental Practice, we go out of our way to help people overcome their nerves and have a calm and positive experience at our surgery.

We invite you to pop into the surgery before you book an appointment so that you can have a look around, meet the dentist and put yourself at ease with the friendly surroundings.

Caring and high-quality dentistry since 2003

When it opened, 42 was one of the first truly multidisciplinary dental practices in the UK. Before then 42, Pembridge Road had been a doctors surgery (Since the 40's and 50's) and had always played a key role in managing the health of Notting Hill.

Over the years, our unique dental practice has been fortunate to build the trust of many patients (both locally and from far and wide) who have become friends of the practice and introduced their families. We have treated several generations and have become very embedded in Notting Hill's' wonderful and diverse community.

During this period we have also built some great relationships with our close network of referring dentists. Our team reflect the ethos of the practice with their significant experience, the highest level of training and expertise and importantly, for many who visit us, all share the same humanistic and gentle approach.

Meet our Team

Confidential Medical history form

Confidential Medical history form

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PATIENT DETAILS

Patient Name *

First

Last

Title *MstMrMrsMissMsMxSirDameDrProfCllrDukeDuchessLadyLordMr PresidentAdmiralGeneralColonelCaptainFatherDoctorEarlBaronBaronessCountPrime MinisterRt.HonHonRt RevRevMost RevBishopRabbiChief RabbiCantorMost Holy FatherChairmanImamSheikhother

Preferred name

Date of Birth *

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Sex *MaleFemaleTransgender MaleTransgender FemaleUnspecified

Address *

Address Line 1

City

State / Province / Region

Email *

Contact Number *

Patient Current or Previous Occupation *

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name

First

Last

Contact Number

Relation to Patient

Dr/GP details

as tobacco, in

Doctor's name

First

Last

Telephone number

Address

Address Line 1

City

State / Province / Region

Medical history. Please answer following questions:

Are you currently

Receiving treatment from a doctor, hospital or clinic? *

• Yes
• No

Please give details:

Taking any prescribed medicines (eg. warfarin, bisphosphonates, or other tablets, ointments, injections or Inhalers, including contraceptives and hormone replacement therapy)? *

• Yes
• No

Please give details:

Pregnant or possibly pregnant? *

• Yes
• No

Please give details:

Carrying a medical warning card? *

• Yes
• No

Please give details:

Have you ever had

Allergies to medicines (eg penicillin), materials (eg latex/rubber, Nickel) or foods? *

• Yes
• No

Please give details:

Bronchitis, asthma or other chest condition? *

• Yes
• No

Please give details:

Fainting attacks, giddiness, blackouts, epilepsy? *

• Yes
• No

Please give details:

Heart problems, angina, blood pressure problems, or stroke? *

• Yes
• No

Please give details:

Diabetes (or does anyone in your family)? *

• Yes
• No

Please give details:

Bone or joint disease? *

• Yes
• No

Please give details:

Bruising or persistent bleeding following injury, tooth extraction or surgery? *

• Yes
• No

Please give details:

Liver disease (eg jaundice, hepatitis) or kidney disease? *

• Yes
• No

Please give details:

Any other serious illness or Infectious disease? *

• Yes
• No

Please give details:

Blood refused by the Blood Transfusion Service or any other agency abroad? *

• Yes
• No

Please give details:

A bad reaction to general or local anaesthetic? *

• Yes
• No

Please give details:

Treatment that required you to be in hospital? *

• Yes
• No

Please give details:

Heart surgery or a stent? *

• Yes
• No

Please give details:

Any form of mental illness (e.g. depression, anxiety, stress, eating disorders)? *

• Yes
• No

Please give details:

Alcohol

How would you describe your consumption of alcohol? *

• Non drinker
• Modest
• Moderate
• More than is good for me
• Heavy

Smoking

Do you smoke any tobacco products now (or did you in the past)? *

• Yes
• No
• In the past

times per day

Selected Value: 0

Do you chew tobacco, pan, use gutkha, supari, or betel now (or did you in the past)? *

• Yes
• No
• In the past

times per day

Selected Value: 0

Do you vape/use electronic cigarettes? (or did you in the past)? *

• Yes
• No
• In the past

times per day

Selected Value: 0

Please give any other details which your dentist might need to know about, such as self-prescribed medicines (eg aspirin) or any disabilities or health concerns you may have.

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Date *

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