Do you consent to the use of your PPS No. to check your eligibility for treatment under the PRSI scheme?
If yes please provide PPS no
Do you consent to be recalled by text message/phone call/email for the purposes of continuing treatment and/or routine check-up?
How is your general health?
Have you consulted a physician for any illness in the last 2 years?
Are you currently taking, or have recently taken any prescription/ non prescription medications?
Have you been hospitalised in the last 2 years?
Do you have any allergies?
Do you bleed excessively when cut or bruise easily?
Are you currently taking or have you taken cortisone/ steroids?
Do you smoke or use other forms of tobacco?
Are you, or do you suspect you may be pregnant?
Do you have or have you ever had
Radiation Treatment to Head or Neck?
Artificial Joints (hip/ knee)?
Do you have any other serious illness? If so please state
When was your last dental check-up?
Have you recently returned from a trip abroad?
If YES, where have you returned from?
Signed (Patient/ Parent or Guardian)