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.
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?*

3 Station Rise, Tulse Hill, SE27 9BW455 Bromley Road, Bromley, BR1 4PH
Have you visited the practice before?

YesNo
NHS Exempt Criteria

Please select the option which applies to you
Category A*

I am under 18 years of ageI am 18 years of age and in full time educationI am pregnantI had a baby in the last 12 monthsNone of the above
Category B*

I am currently in prison or a young offenders instituteIncome Support (Incapacity benefit and Disability)Income-based Jobseeker's AllowanceIncome-related Employment & Support AllowancePension Credit Guarantee CreditUniversal Credit and meets the criteria. (Find out more at www.nhsbsa.nhs.uk/UC)HC2 CertificateHC3 CertificateNHS Tax Credit Exemption Certificate/CardNone of the above
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?*

GoodFairPoor
What are the current issues you have with your teeth?*

Bleeding GumsPain and ToothacheCrooked TeethCosmetic ConcernsWobbly teethBad BreathFood TrappingSensitivityDenturesMissing TeethWant Whitening
Are you happy with your teeth and their overall appearance?*

YesNo
Have you ever had a tooth extracted due to an accident, tooth decay or gum disease?*

YesNo
Have you ever had any complications following dental treatment, for example an extraction?*

YesNo
Do you use any of the following as part of your Oral Hygiene Regiment?*

Electric toothbrushManual toothbrushFlossTEPE brushesToothpickWater flosserFluoride mouth wash or mouth rinseFluoride toothpasteFluoride-free toothpaste
Are you anxious when attending dentist appointments?*

Not anxious at allFairly anxiousModerately anxiousHighly anxious and very nervous
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:

NHS Appointment Form

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

NHS Exempt Criteria

Dental History

Thank you for taking the time to complete this form. A member of staff will be in touch within 24 hours