2 Guildford Road
Bagshot
Surrey
GU19 5JH
info@dentistbagshot.co.uk

New Patient Registration Form - NHS

In order for us to provide you with the best care, please complete the following confidential questions: (*-compulsory fields)

Note: We regret that we currently are not able to accept any new NHS patients.
You may still register your interest in becoming an NHS patient. We keep a waiting list, but we will not be able to book appointments until later in the year.

Personal Assessment and Medical History

NHS Number*:

Title*:

Name*:

Surname*:

DOB*:(dd/mm/yyyy)

Address*:

City*:

Postcode*:

Email*:

Tel:(incl.country code)

mob*:

How did you hear about us:

Date of last dental examination: (dd/mm/yyyy)

Date of last hygiene appointment: (dd/mm/yyyy)

General Practitioner name:

General Practitioner address and phone number:

The Health Questions below are important to your dentist. Do not worry about questions you cannot answer, but feel free to discuss them further with your dentist.

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

If yes please give details in space on the right.

2. Taking any prescribed medicines?:

If yes please give details in space on the right.

3. Carrying a medical warning card?:

If yes please give details in space on the right.

4. Are you pregnant/expecting a baby?:

If yes please give details in space on the right.

5. Allergies to any medicines, substances or food?:

If yes please give details in space on the right.

6. Bronchitis, asthma or other chest conditions?:

If yes please give details in space on the right.

7. Fainting attacks, giddiness, blackouts, epilepsy?:

If yes please give details in space on the right.

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

If yes please give details in space on the right.

9. Diabetes (or does anybodyin your family)?:

If yes please give details in space on the right.

10. Bone or joint disease?:

If yes please give details in space on the right.

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

If yes please give details in space on the right.

12. Liver disease or kidney disease?:

If yes please give details in space on the right.

13. Any other serious illness or infectious disease?:

If yes please give details in space on the right.

14. A bad reaction to general or local anaesthetic?:

If yes please give details in space on the right.

15. Ever had a serious illness or operation that required you to be in hospital?:

If yes please give details in space on the right.

16. Heart surgery?:

If yes please give details in space on the right.

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

You can add comments in the field on right.

18. Do you smoke tobacco products now (in the past)?:

If yes please give details in space on the right.

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

If yes please give details in space on the right.