NHS registration information
In order to enable us to book you in with the appropriate clinician, please fill in all fields below.
Personal Information
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Gender
*
Please Select
Female
Male
Not willing to disclose
First line of address
City
Postcode
Home phone
*
Please enter a valid phone number.
Format: (00000) 000000.
Work phone
*
Please enter a valid phone number.
Format: (00000) 000000.
Mobile
*
Please enter a valid phone number.
Format: (00000) 000000.
Email
*
example@example.com
Do you have any dependents?
*
Yes
No
Name
Relationship
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Medical History
Pre existing Medical Conditions
*
Pre existing Allergies
*
Current Medications
*
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Dental History
Last treatment date
*
-
Day
-
Month
Year
Date
Known dental issues or concerns
*
Name and contact details of previous dentist
*
To transfer any records
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Your Comfort
Do you require a ground floor surgery?
*
Please Select
Yes
No
Is there anything else you feel will make us care for you better?
*
To transfer any records
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Exemptions & Remissions
Do you believe you may be entitled to free NHS treatment?
*
Please Select
Yes
No
Please state why?
To transfer any records
Would you be interested in joining our prevention plan with the hygienist/ therapist at £16 per month (this is a private treatment twice a year with a deep scale and stain removal program)?
*
Please Select
Yes
No
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Consent and Authorization
Do you consent for us to provide dental treatment
*
Please Select
Yes
No
Do you consent for release of medical/ dental records from previous dentist
*
Please Select
Yes
No
Do you confirm the information on this form is accurate
*
Please Select
Yes
No
Do you consent for us to us contacting for future marketing
*
Please Select
Yes
No
How did you find us?
*
Please Select
Friend/ Family recommendation
Google
Other search engine
Poster/ Signage
Article
Other
Please provide name/ details
*
Signature
*
Date
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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