Patient Registration (2023)

1
Are you completing this form on behalf of someone else?* This field is required.Only complete this form on behalf of someone else if you will be managing their appointments and treatment, e.g. you are their carer or you are their parent. In all other cases, the patient should complete this form themselves.
YesNo
2
What is your name as the third party?* This field is required.
Title
First Name
Last Name
3
Is the patient a child?* This field is required.A child is anyone under the age of 18.
YesNo
4
What is your relationship to the patient?* This field is required.If you are not a parent or carer but need to register a patient as a third party please contact us on 0808 164 1003 to discuss further.
Parent
Carer
5
What is your name?* This field is required.If you are completing this on behalf of the patient, enter the patient's name here.
Mr
Mr
Mrs
Miss
Ms
Dr
Master
Prof
Hon
Rev
Sir
Lady
Lord
Earl
Judge
Dame
Title
First Name
Last Name
6
What is your address?* This field is required.If you are completing this on behalf of the patient, enter the patient's address here.
Street Address
Street Address Line 2
Town / City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
What is your biological sex?* This field is required.If you are completing this on behalf of the patient, enter the patient's gender.
Male
Female
8
What is your date of birth?* This field is required.If you are completing this on behalf of the patient, enter the patient's date of birth.
Date
Day
Month
Year
9
What is the best phone number to reach you on?* This field is required.If you are completing this form on behalf of a patient, enter your phone number. Please use a mobile number if you have one, so we can text you when relevant.
10
What is the best email address to use?* This field is required.If you are completing this form on behalf of a patient, enter your email address. You will need to verify your email address is correct by entering a verification code.
example@example.com
11
Why are you looking for an appointment?* This field is required.If you require an urgent appointment, please call us instead on 0808 164 1003.
I want to register for routine care
I would like cosmetic treatment
I have a dental problem or concern
12
Tell us a bit more about your requirements.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Which location would you like to register with?* This field is required.
Colwyn Bay
Llangefni
Porthmadog
14
Why are you changing dentist?* This field is required.Please select the option which most closely matches your circumstances.
I am not currently registered with a dentist
My dentist is closing
My dentist cannot complete treatment I require
I am unhappy with my existing dentist
I have recently moved to the area
15
How did you hear about us?* This field is required.
Referred by an existing patient
Referred by my current dentist
Facebook
Instagram
Google advert or search
Newspaper advert
Walked past
Word of mouth
Audio / radio
Postal marketing
16
Have you visited West End Dental in the past?* This field is required.
YesNo
17
What are the best days for an appointment?* This field is required.Choose all that apply. We cannot guarantee that we will be able to offer an appointment on your chosen days.
Monday
Tuesday
Wednesday
Thursday
Friday
18
What is the best time of day for an appointment?* This field is required.Choose all that apply. We cannot guarantee that we will be able to offer an appointment at your chosen time.
8am to 11am
11am to 1pm
1pm to 3pm
3pm to 5pm
19
Do you experience any of the following?* This field is required.
Yes
No
Sensitivity (hot / cold / sweet)
Row 0, Column 0
Row 0, Column 1
Pain or discomfort
Row 1, Column 0
Row 1, Column 1
Headaches
Row 2, Column 0
Row 2, Column 1
Loose or shifting teeth
Row 3, Column 0
Row 3, Column 1
Bad breath
Row 4, Column 0
Row 4, Column 1
Sensitivity (hot / cold / sweet)
Pain or discomfort
Headaches
Loose or shifting teeth
Bad breath
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
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20
Do you or have you had any of the following?* This field is required.
Currently
In The Past
Never
Dentures
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Braces
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Periodontal (Gum) Treatment
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Veneers
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Tooth Whitening
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Dental Implants
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Dentures
Braces
Periodontal (Gum) Treatment
Veneers
Tooth Whitening
Dental Implants
Currently
Row 0, Column 0
In The Past
Row 0, Column 1
Never
Row 0, Column 2
Currently
Row 1, Column 0
In The Past
Row 1, Column 1
Never
Row 1, Column 2
Currently
Row 2, Column 0
In The Past
Row 2, Column 1
Never
Row 2, Column 2
Currently
Row 3, Column 0
In The Past
Row 3, Column 1
Never
Row 3, Column 2
Currently
Row 4, Column 0
In The Past
Row 4, Column 1
Never
Row 4, Column 2
Currently
Row 5, Column 0
In The Past
Row 5, Column 1
Never
Row 5, Column 2
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21
If you could change your teeth, would you...* This field is required.
Yes
No
Make them straighter
Row 0, Column 0
Row 0, Column 1
Close spaces
Row 1, Column 0
Row 1, Column 1
Replace metal fillings
Row 2, Column 0
Row 2, Column 1
Repair chipped teeth
Row 3, Column 0
Row 3, Column 1
Replace missing teeth
Row 4, Column 0
Row 4, Column 1
Replace old crowns
Row 5, Column 0
Row 5, Column 1
Have a smile makeover
Row 6, Column 0
Row 6, Column 1
Make them whiter
Row 7, Column 0
Row 7, Column 1
Make them straighter
Close spaces
Replace metal fillings
Repair chipped teeth
Replace missing teeth
Replace old crowns
Have a smile makeover
Make them whiter
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
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22
Do you consider yourself a nervous patient?* This field is required.
YesNo
23
Payment* This field is required.Please select your consultation type below. Please ensure Complimentary Consultation is selected if you wish to book a free appointment. You do not need to enter card details if choosing a Complimentary Consultation.
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ORDER SUMMARY
Total costGBP
Initial ConsultationInitial 30 minute consultation with one of our dental surgeons at your chosen West End Dental practice.
£40.00Edit
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Complimentary ConsultationFree 15 minute consultation with one of our dental surgeons at your chosen West End Dental practice. Please see our Terms of Business.
£FreeEdit
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Total cost £0.00
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24
Terms and Conditions* This field is required.
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