Patient Registration
Thank you for taking the time to fill the form below. Please complete it in as much detail as possible. Your answers are important to us and help us with ensuring your needs.


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Email *
Full Name: *
Date of Birth *
Phone Number *
Address *
Occupation *
Medical & Dental History
It is important that you fill this section out to the best of your knowledge.
What sort of treatments are you interested in?
When was your last dental visit: *
Please select all that apply
Required
Do you have a regular dentist (if yes, please list the practice name)? *
Have you had any of the dental treatments listed below?
Clear selection
Have you had dental treatment with another dentist in another country? Yes (please specify country & type of treatment)
Do you have any treatment currently pending/ongoing?
Are you seeking a second opnion?
Have you needed any emergency dental treatment in the last 12 months?
If yes, what was carried out
Do you have any dental concerns or anxieties?
Are you undergoing any hospital treatment or have any medical conditions we should be aware of?
Do you have any allergies? *
Please list out any medications you are on
Payments/Exemptions
Do you have any NHS dental charge exemptions? (Please note we cannot take responsbility if you claim incorrectly. There is a fine from NHS BSA for incorrect calims)
If yes, please tick the reasons that apply: 
Do you have medical/dental insurance? Please give as much detail as possible
Please state how you were referred to this practice or by whom?  *
Practice Policy and Waiting List
Thank you for taking the time to fill out this form. We routinely review the information. Please note due to very high demand for NHS appointments it may take some time before something becomes available, however we will try our best to see those that need in a timely fashion.
Therefore, it is important when offered: You attend the practice every 6 months and follow the cancellation policy. 
Understand that a deposit will be taken for all appointments 
Understand the importance of following the dentists advice on treatment and getting it done in a timely fashion.
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