New Patients

New patients should complete the form below so we have an idea of your dental history. Note that your information will not be stored online or anywhere on our website, it will be emailed directly to our admin staff for filing and then removed.

* = required field

Full Name (Mr/Mrs/Miss/Ms) *

Date of birth *

Address *

Telephone (home or work) *

Telephone (mobile)

Occupation and work address

General medical practitioner *

Nearest relative (not at your address) *

Person responsible for fees *

What dental insurance (if any) do you have

How did you discover the surgery *

PLEASE CHECK APPROPRIATE BOXES *
None of theseDo you take drugs/medicines regularly?Have you had any serious health problems during the past year?Have you had any adverse reaction to any treatment or medication (e.g. Penicillin, Latex, Codeine, Adrenaline, Morphine, Sulphur etc)?^

DO YOU SUFFER FROM *
None of these1. Heart/vascular disorder#2. Blood disease/bleeder3. Blood pressure problem4. Diabetes5. Arthritis6. Liver or kidney disease7. Asthma8. Epilepsy9. Allergy/Hypersensitivity10. Rheumatic Fever#
# If you have a history of rheumatic fever, a heart murmur or a heart valve disorder/replacement you may require antibiotic cover. Please contact the surgery prior to your appointment.

Any other medical conditions (please give details)

PLEASE TICK ANY OF THE FOLLOWING WHICH CURRENTLY AFFECT YOU *
None of these1. Toothache2. Sensitive teeth (hot/cold)3. Bleeding gums4. Loosened teeth5. Unsatisfactory denture6. Worn broken teeth7. Chewing is difficult8. Discoloured teeth9. Pain in face or jaw joints10. Lost filling – cavity11. Missing teeth12. Others

Are you pregnant *
NoYesNot relevant

Do you snore or suffer from obstructive sleep apnoea? *
NoYes

Do you have a high sugar intake? *
NoYes *

The HIV and HEPATITIS B & C Viruses can be present in the blood and saliva. This puts the dentist and the staff who will treat you in a vulnerable position when attending patients who fall in the “HIGH RISK” category of either disease.
High risk categories have been identified as: carriers of hepatitis B & C or HIV infection; homosexual and bisexual intravenous drug users; sexual partners of all mentioned above. Please tick the appropriate alternative: *
No I am not in the high risk categoryYes I could be in a high risk categoryI will notify the dentist in person at my first visit

If the answer is YES special precautions will be taken to protect you, other patients and staff.

Often dental treatment is carried out under local anaesthesia. Have you had any adverse reactions to local anaesthetic before? *
NoYes

Your appointment times will be set aside for you personally. Where possible, we request that you give a minimum of 24 hours notice if you can't commit to your appointment. Unless prior arrangement is made, payments for service are to be made on the day of treatment.

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