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Call Now: 01932 808573

Fax - 01932 829 946

Roadway House, 35 Monument Hill,
Weybridge, Surrey KT13 8RN

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Visit The Denture and Implant Clinic, Weybridge to solve your denture problems!
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New Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.

About you

Title :

MrMrsMsDr

*Last name :

Middle name :

*First name :

I prefer to be called :

Sex : MaleFemale

*Your birthday :

Age:

*Home address :

	City		County
	Postcode		APT#

*Email address :

Marital Status :

SingleMarriedPartneredDivorced / SeparatedWidowed

Telephone :

*Home :

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Work :

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Mobile :

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Occupation :

Where & when are best times to reach you?

How did you hear about us? Have you visited our website? YesNo

Whom may we Thank for referring you?

Other family members seen by us :

Previous dentist :

Present dentist :

Last Visit Date :

Spouse information

His / Her name :

Telephone work :

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Birthday :

In the event of an emergency, is there someone who lives near you that we should contact?

His / Her Name :

Relationship :

Home phone :

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Work phone :

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Dental History

What is the reason for your visit today?
How do you consider your current dental health?	GoodFairPoor
Do you like your smile?	YesNo
Are you happy with the color of your teeth?	YesNo
Do your gums bleed?	YesNo
How many times a day do you brush?	Floss?
How long do you use a toothbrush before replacing it?
What type of toothbrush bristles do you use?	HardMediumSoft
Are your teeth sensitive to	HeatCold
Are you dental phobic?	YesNo
When was your last dental cleaning?

Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a Doctor’s care now?	Yes No	If yes, Please explain
Have you ever been hospitalized or had a major operation?	Yes No	If yes, Please explain
Have you ever had a serious head or neck injury?	Yes No	If yes, Please explain
Are you taking any medications, pills or drugs?	Yes No	If yes, Please explain
Are you on a special diet?	Yes No
Do you use tobacco?	Yes No
Do you use controlled substances?	Yes No

Women : Are you

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?	Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other
Please explain :

Do you have, or have you had, any of the following?

	AIDS/HIV Positive
	Alzeheimer’s Disease
	Anaphylaxis
	Anemia
	Angina
	Arthritis/Gout
	Artificial Heart Valve
	Artificial Joint
	Asthma
	Blood Disease
	Blood Transfusion
	Breathing Problem
	Bruise Easily
	Cancer
	Chemotherapy

	Chest Pains
	Cold Sores/Fever Blisters
	Congenital Heart Disorder
	Convulsions
	Cortisone Medicine
	Diabetes
	Drug Addiction
	Easily Winded
	Emphysema
	Epilepsy or Seizures
	Excessive Bleeding
	Excessive Thirst
	Fainting Spells/Dizziness
	Frequent Cough
	Frequent Diarrhea

	Frequent Headaches
	Genital Herpes
	Glaucoma
	Hay Fever
	Heart Attack/Failure
	Heart Murmur
	Heart Pace Maker
	Heart Trouble/Disease
	Hemophilia
	Hepatitis A
	Hepatitis B or C
	Herpes
	High Blood Pressure
	Hives or Rash
	Hypoglycemia

	Irregular Heartbeat
	Kidney Problems
	Leukemia
	Liver Disease
	Low Blood Pressure
	Lung Disease
	Mitral Valve Prolapse
	Pain in Jaw Joints
	Parathyroid Disease
	Psychiatric Care
	Radiation Treatments
	Recent Weight Loss
	Renal Dialysis
	Rheumatic Fever
	Rheumatism

	Scarlet Fever
	Shingles
	Sickle Cell Disease
	Sinus Trouble
	Spina Bifida
	Stomach/Intestinal Disease
	Stroke
	Swelling of Limbs
	Thyroid Disease
	Tonsillitis
	Tuberculosis
	Tumors or Growths
	Ulcers
	Venereal Disease
	Yellow Jaundice

Have you ever had any serious illness not listed above?

Yes No

If yes, Please explain


	* I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

*Signature :

Date :

Portmore Dental Office located at Roadway House, 35 Monument Hill, Weybridge, KT13 8RN, Surrey. Phone: 01932 808573. www.portmoredental.co.uk