New Patient Registration Form

Please provide us with information about your personal details and general health to help us treat you safely. Do not answer any questions you do not understand. You will have the  opportunity to discuss any queries with your dentist who will be happy to answer any of  your questions. All information will be kept strictly confidential.

Patient Details:

Emergency Contact:

By completing this section you consent to the practice contacting your emergency contact in the event of a medical emergency 

Medical History

Please ensure that the health information on this form is full and correct. Please ensure that you inform us of any changes to your smoking, alcohol or medicine intake and request a medical history update form as soon as possible.

e.g. tablets, ointments, injections, inhalers, eyedrops, suppositories, nebulisers, the contraceptive pill or HRT

Did you, as a child or since, have any of the following:

Did you, as a child or since, have any of the following:

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.