New Patients

Register with us

Complete the form below and our reception team will be in touch to book your first appointment.

Please note: our NHS books are currently full and we are unable to accept new adult NHS patients at this time. We are pleased to accept new NHS patients under the age of 18, and we are accepting new private patients of all ages. Please call us on 01276 472 245 if you have any questions.

Your information is kept strictly confidential and used only for your dental care. Once submitted, our reception team will contact you to confirm your appointment.

1 Personal Details

Title *

First Name *

Surname *

Date of Birth *

Email Address *

Address *

City *

Postcode *

Country Code *

Contact Number *

How did you hear about us?

2 Dental History

Date of last dental examination

Date of last hygiene appointment

General Practitioner (GP) Name

GP Address and Phone Number

3 Medical History

Please answer the following questions. Select Yes, No, or Not Applicable for each.

1. Received treatment from a doctor, hospital or clinic?

2. Taking any prescribed medicines?

3. Carrying a medical warning card?

4. Are you pregnant or expecting a baby?

5. Any allergies to medicines, substances or food?

6. Bronchitis, asthma or other chest conditions?

7. Fainting attacks, giddiness, blackouts or epilepsy?

8. Heart problems, angina, blood pressure problems or stroke?

9. Do you or anyone in your family suffer from diabetes?

10. Bone or joint disease?

11. Bruising or persistent bleeding following injury, extraction or surgery?

12. Liver disease or kidney disease?

13. Any other serious illness or infectious disease?

14. A bad reaction to general or local anaesthetic?

15. Ever had a serious illness or operation requiring hospital admission?

16. Heart surgery?

17. How many units of alcohol do you drink per week?

18. Do you smoke tobacco products, or have you done so in the past?

19. Do you chew tobacco, pan, use guthka or supari (now or in the past)?