First name:

Title:

Surname:

Date of Birth

Sex:

Address

Post Code

Home Tel no:

Work Tel no:

Mobile no:

1.                Eventually we will be using text manager to remind you of your appointment, would you like to be reminded in that way?

Yes

No

2.                  Would you like email reminders for your appointments?

Yes

No

Email Address:

Previous Name:

Occupation:

Work address:

Post code:

Doctors Name:

Address:

3.                  Do you go to the dentist

6monthly

12 monthly

Never

Only when having pain?

4.                Why did you leave your last dentist?           

5.                Have you got any problems your previous dentist was watching?

Yes

No

6.                Would you say you have (please tick accordingly),

A low risk of having fillings.

A filling every so often.

A filling, every time you visit the dentist.

More than one filling, every time you visit the dentist.

7. Is there anything your last dentist did that you particularly liked?

8. Has anyone ever showed you how to brush your teeth properly?

Yes

No

9. Have you had any of the following treatments?

Crown

Yes

No

Root treatment

Yes

No

Surgical treatment

Yes

No

Gum disease

Yes

No

Periodontal disease

Yes

No

Denplan or Bupa

Yes

No

Specialist treatment

Yes

No

Extractions

Yes

No

Toothache

Yes

No

10.              Did your parents loose their teeth at a young age?

Yes

No

11.              Are your parents frightened of going to the dentist?

Yes

No

• NHS Registration only last for 15 months after this the NHS removes you from our list. Normally we send out a letter telling you of this fact.

• Late, if you are 10mins late this will more often than not make us rebook the appointment, this is due to the fact we do not like to rush our work.

• Failure to appointment

1^st appointment, you will need to place a £20 deposit to make another appointment, this deposit will be kept if the second appointment is not attended.

Two(2) failed appointments in 2 years  will result in the removed from our patient list.

Marital status

Will your partner require a dentist at their practice

Yes

No

Do you have any children?

Yes

No

Will they require to be seen at this practice?

Yes

No

Occupation

Which days do you prefer to be seen?

Monday

Tuesday

Wednesday

Thursday

Friday

Will you require out of hours appointments?

Yes

No

The practice has a private evening appointments available. Will you be interested in taking advantage of these appointments

Yes

No