•  :
  • Gender*
  • Would you like to register as a family?*

  • Patient Dental & Medical History

  • Please select the practice you would like to be seen at (you may select 3 closest to you):

  • Please note in some cases and only if required we may refer you to one of our specialist treatment practices outside of your selection above.

  • How did you hear about us?

  • What type of service would you like to receive (choose one)?*
  • Are you entitled to free NHS dental services? (You will be asked to present evidence at a later stage before any treatment commences)*
  • What best describes your dental attendance pattern and reasons for joining? (You may select multiple)*
  • What options are you hoping to achieve from your visit with us?  (You may select multiple)*

  • When was your last dental visit?

  • When was your last hygienist visit?

  • Are you covered by dental insurance?*

  • Your Appointment

  • What days of the week are best for your appointments?
  • Do you worry about your dental visit?

  • Medical History

  • Please tick any that may apply to you*
  • Are you or could you be pregnant?
  • Blood pressure
  • Diabetic type
  • Do you drink alcohol?*
  • Do you smoke?*

  • Emergency Contact Info

  • Your Smile

  •    
  • Are you interested in improving your smile?
  • Please select the statements applicable to you. I would like my

  • Your Gum Health

  • Please tick any applicable to you:

  • Your Teeth & Jaw Health

  • Please tick any applicable to you:

  • Dentures & Implants

    Please complete only if applicable to you:
  • Do you wear a denture?
  • Are you happy with your current dentures?*
  • Do you have dental implants?
  • Are they being maintained?*

  • Consent

  • Consent for use of clinical data at GDCG Ltd:

    Please note that all treatment carried out at GDCG LTD is documented potentially physically, photographically and on video as part of your clinical record such as:

    • Sharing data, such as impression moulds, with dental laboratories in order for them to make medical devices such as crowns, bridges, mouthguards and dentures.
    • Sharing clinical records with medical and or dental colleagues if you need a referral
    • Sharing medical records to a medical colleague if sedation is required
    • 3rd parties directly involved with your clinical care

    We do not sell data to any third parties and when we share data it will be a limited amount of information that is needed to improve your clinical care.

    We are bound by the current General Data Protection Regulation (GDPR) 2018. (Please see GDCG LTD's current Terms and Conditions.)

  • I consent for data and image to be shared as described above*

  • Please email us on manager@gentledentalcaregroup.co.uk with your concerns or questions and kindly copy in the name of your dentist and when your appointment time is alongside your name to ensure we assist you as quickly as possible. Thank you

  • Please email us on info@thedentureclinic.co.uk with your concerns or questions and kindly copy in the name of your dentist and when your appointment time is alongside your name to ensure we assist you as quickly as possible. Thank you

  • I consent for use of clinical images and video As well as being a necessary and indispensable part of your clinical record, these images may be used anonymously for the purposes of teaching, conference presentation, website, articles or promotional material, in the UK and abroad.*
  • Are you registering on behalf of someone? (Parent/Carer)*
  • Should be Empty: