Registration Form

New Patient Questionnaire and Medical History

Please take some time to complete the form below. This will save you time on your first visit. To book your first appointment, please just give us a call on 020 7935 9233. You can complete this form in the practice on your first visit. Please arrive early to allow a minimum of 10 minutes before your allotted time to complete the form. Alternatively drop us an email [here] and we'll get back to you.

If you require support in filling out your form, or more information in large print please contact us on 020 7935 9233 or

Name *
Date of Birth *
Date of Birth
Please enter your gender. (If transgender please identify which gender you would like to be recognised as).
Address *
Please add your preferred contact telephone number.
Please let us know how you found out about the practice.
If someone else will be paying your bill, please provide their information here.
Are you covered by any medical insurance?
Do you have a particular dental problem at present, or wish to seek a specific treatment plan? If 'Yes' please fill out details in the box below.
If you answered 'yes' to the previous question, please describe in detail here.
If you selected yes, please detail in the text box below.
Please complete if you answered 'yes' to the previous question.
This can be in units or an approximate measure
e.g. heart valve or joint replacement
If male, please continue to the question after next.
Please let me know at any point during your dental treatment if you think you may be pregnant, especially if X-rays are indicated. It is important to remember that antibiotics can reduce the effectiveness of birth control pills.
If 'Yes' then please specify which below.
Please answer 'Yes' or 'No' to the following questions and provide any details if necessary.
Do you have, or have you ever had, any of the following? *
Check the conditions you have, or select 'None' at the bottom.