Home Treatments Price List Meet The Team FAQ Register With Us How To Find Us Contact Us
 

If you wish to join the practice, please feel free to telephone the surgery to talk to a member of staff who will be happy to send you some registration forms or alternatively you can fill out the forms below and they will be sent to us via e-mail.

PLEASE NOTE, AS THIS WEBSITE IS CURRENTLY UNDER GOING CONSTRUCTION PLEASE DO NOT USE THE BELOW FORM UNTIL THIS MESSAGE DISAPPEARS AS WE ARE EXPERIENCING SOME PROBLEMS.

 

Part One - Personal Details

Full Name  

Address (including Post Code)

Date of Birth  

Telephone Number (home)

Telephone Number (work) 

Mobile 

E-mail address 

Part Two - Medical History

Are you currently:-

                                                                                                                     Yes             No                          Details

Pregnant?                                                                                                                              

Receiving treatment from a doctor, hospital or clinic?                                                      

Taking any Medicines? (Include all)                                                                                    

Carrying a medical warning card?                                                                                      

 

Do you suffer from any of the following:-

 

Allergies to any medicines, substances or foods?                                                            

Hay Fever or eczema?                                                                                                          

Bronchitis, asthma or other chest condition?                                                                      

Fainting, giddiness, black outs or epilesy?                                                                         

Heart Problems, blood pressure problems or stoke?                                                        

Diabetes (anyone in the family?)                                                                                          

Arthritis?                                                                                                                                  

Bruising or persistent bleeding following trauma?                                                              

Any Infectious diseases? (including HIV and Hepatitus)                                                    

 

Did you, as a child or since, have:-

 

Rheumatic fever or chorea?                                                                                                  

Liver disease or kidney disease?                                                                                        

Any other serious illness?                                                                                                      

Blood refused by the Blood Transfusion Service?                                                              

A bad reaction to anaesthetic?                                                                                             

A joint replacement or other implant?                                                                                   

Treatment that required you to be in hospital?                                                                     

Heart surgery?                                                                                                                         

Brain surgery?                                                                                                                         

Growth Hormone treatment before 1980's?                                                                         

A close relative with Creutzfeldt Jakob Disease?                                                               

 

Part Three - Dental History

When did you last visit the dentist?

Have you attended regular treatment over the last 2 years?                                              

Why did you leave your last dentist?

What aspects of treatment trouble you the most?

Have you ever suffered ill effects after treatment?                                                               

Have you ever bleed seriously after an extraction?                                                             

Do you clinch or grind your teeth?                                                                                         

Do you expect to loose teeth in the future?                                                                          

Does the idea of wearing a denture bother you?                                                                

Are you happy with the appearance of your teeth?                                                             

 

Do you suffer from any of the following conditions:-

 

Bleeding Gums?                                                                                                                     

Sensitive Teeth?                                                                                                                     

Dry Mouth?                                                                                                                              

Headache?                                                                                                                             

Jaw joint pains?                                                                                                                      

Sinus problems?                                                                                                                    

Mouth ulcers?                                                                                                                          

Bad breath?                                                                                                                             

Is there any further information relevant to you dental care?                                               

 

Part Four - Social History

Occupation

Alcohol - approximate weekly consumption?                                                                       

Tabacco - approximate weekly consumption?                                                                     

Do you take part in any physical contact sports?                                                                 

Do you place any instruments with your mouth?                                                                   

 

Part Five - Paying for your Treatment

 

Are you in receipt of any state benefits?                                                                               

 

The practice offers treatments to patients on the National Health Service, privately and on a private capitation scheme. Private capitation is payment of a fixed monthly fee to cover the cost of examinations, cleaning of teeth and fillings.

Please tick if you would like further information

 

Notes - Please feel free to tell us about anything relevant to your dental treatment no covered in this form

 
 

Sole Owner and Principle Dental Surgeon - Dr Michael Ryan B.D.S; D.G.D.P (UK)