New Patient Questionnaire

We like to feel that the dental care which we will provide for you, within a friendly relaxed atmosphere, is not only of the highest quality, but also that we are sensitive to your particular needs and requirements

To help maximise benefit from your first appointment, we ask all new patients to the practice to complete a New Patient Questionnaire and a Medical History Form, both of which can be found by clicking on the link above

We are currently not accepting any new NHS patients, to be added to our waiting list, please complete these questionnaires and click send when completed.

Thank you

Name *

DOB: *

Address: *

Post Code: *

Telephone Number *

Email

Doctor’s name: *

Address: *

Telephone number: *

Date of last dental Visit *

Routine / Emergency Visit? *

Routine Visit
Emergency Visit

If you were recommended by a friend who recommended you?

Other (please specify)

How much do you worry about a dental visit? *

A lot
A bit
Not really
Not at all

What do you worry about most in a dental visit? (please give details)

How highly would you rate the importance of a good appearance for your mouth? *

Very
Fairly
Not at all

How important is it for you to keep your own teeth? *

Very
Fairly
Not at all

Do you take active steps to keep fit and healthy? *

Yes
No

Do you play contact sports or hazardous leisure activities? *

Yes
No

Do you take sugar in drinks? *

Yes
No

Do you consider that you take diet and nutrition seriously? *

Yes
No

Is there anything else you feel we should know about you and your life style?

If you could change anything in your mouth, what would you want it to achieve?

Patient/Parent/Guardian Signed: *

Date: *