NHS Appointment Form

NHS Appointment Form
Please complete all sections to the best of your knowledge. This form should take 1 minute to complete

Thank you
Name

ForenameSurname
Date of Birth

MonthDayYear
Date
Contact number
Please enter a valid phone number.Format: 00000000000.
Email address
Please enter a valid email address
NHS number
Please enter your NHS number if you know it
Which Practice location would you like to attend?
Have you visited the practice before?
NHS Exempt Criteria

Please select the option which applies to you
Category A
Category B
Dental History

Please answer the questions below
When was your last dental visit?
Have you ever had a Hygiene Clean? If yes, when was the last time?
If you have previously attended a different Dentist, where was it?
How would you describe your dental health at this present moment?
What are the current issues you have with your teeth?
Are you happy with your teeth and their overall appearance?
Have you ever had a tooth extracted due to an accident, tooth decay or gum disease?
Have you ever had any complications following dental treatment, for example an extraction?
Do you use any of the following as part of your Oral Hygiene Regiment?
Are you anxious when attending dentist appointments?
If you are anxious, please provide more details that will help us keep you at ease
Thank you for taking the time to complete this form. A member of staff will be in touch within 24 hours

All information provided will remain strictly confidential
Should be Empty:

Please complete all sections to the best of your knowledge. This form should take 1 minute to complete