Cosmetic Dentistry and Dental Implants
Creating Beautiful Smiles

New Patient Application Form

  1. Surname(*)
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  2. Forename(s)(*)
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  3. Date of Birth(*)
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  4. Sex(*)
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  5. Address(*)
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  6. Postcode(*)
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  7. Tel. No (Home)(*)
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  8. Tel. No. (Mobile)
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  9. Tel. No (Work)
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  10. Email
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  11. Expectant Mother
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  12. Doctor's Name, Address and Tel No
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  13. I am giving my permission to be contacted(*)
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    By Completing this form, I am giving my permission to be contacted by correspondence or telephone at the details given above
  14. I have to pay NHS charges(*)
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  15. If No, please enter your exemption details
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    (E.g. Income Support, Tax Credit)
  16. Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?(*)
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  17. Please Give Details
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  18. Are you taking and medicines from a doctor?(*)
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    (tablets, creams, ointments, injections, other)
  19. Please Give Details
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  20. Are you taking or have taken steriods in the last two years?(*)
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  21. Please Give Details
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  22. Are you allergic to any medicines, foods or materials?(*)
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  23. Please Give Details
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  24. Have you ever had rheumatic fever or chorea (St Vitus Dance)?(*)
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  25. Please Give Details
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  26. Have you ever had jaundice, liver, kidney disease or hepatitis?(*)
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  27. Please Give Details
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  28. Have you ever been told you have a heart murmur or heart problem, angina, blood pressure or heart attack?(*)
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  29. Please Give Details
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  30. Have you ever had any blood tests, innoculations etc?(*)
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  31. Please Give Details
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  32. Have you ever had your blood refused by the Blood Transfusion Service?(*)
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  33. Please Give Details
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  34. Have you ever has a bad reaction to general or local anaesthetic?(*)
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  35. Please Give Details
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  36. Have you ever had joint replacement?(*)
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  37. Please Give Details
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  38. Have you ever had brain surgery?(*)
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  39. Please Give Details
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  40. Have you ever had growth hormone treatment before the mid 1980's?(*)
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  41. Please Give Details
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  42. Have you ever had a close relative suffer with Creutzfeldt Jakob Disease?(*)
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    (parent, sibling, child, grandparent or grandchild)
  43. Please Give Details
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  44. Have you ever been hospitalised?(*)
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  45. Please Give Details
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  46. Do you have arthritis?(*)
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  47. Please Give Details
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  48. Do you have a pacemaker, or have you had any form of heart surgery?(*)
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  49. Please Give Details
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  50. Do you suffer from hayfever, eczema or any other allergy?(*)
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  51. Please Give Details
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  52. Do you suffer from bronchitis, asthma, other chest condition?(*)
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  53. Please Give Details
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  54. Do you have fainting attacks, giddiness, blackouts, epilepsy?(*)
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  55. Please Give Details
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  56. Do you have diabetes, or does anyone in your family?(*)
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  57. Please Give Details
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  58. Do you bruise easily or following a tooth extraction, surgery or injury have you or your family bled so as to cause you to be worried?(*)
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  59. Please Give Details
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  60. Do you carry a warning card?(*)
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  61. Please Give Details
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  62. Are there any other aspects concerning your health that you think your dentist should know?(*)
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  63. Please Give Details
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  64. Smoking(*)
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    Did you smoke any tobacco products now or did you in the past?
  65. Quantity Per Day?
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  66. Captcha (Please insert letters shown)(*)
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  67. Please be advised that you will be required to sign and date this form on your first and subsequent examination appointments.