Patient Registration & Medical History PRIVATE AND CONFIDENTIAL "*" indicates required fields 1Patient Registration 2COVID-19 3Dental Questions4Medical History Form5Office use only This field is hidden when viewing the formDate Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Date of Birth*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex* Male Female Contact DetailsAddress Street Address Address Line 2 City County Postcode Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Home Phone NumberMobile NumberEmail Enter Email Confirm Email Newsletter Yes, Sign me up to receive health tips, special offers and much more. OccupationPlease selectAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherOccupation otherEthnicity*Please select your ethnicityWhite -English / Welsh / Scottish / Northern Irish / BritishWhite - IrishWhite - Gypsy or Irish TravellerWhite - Any other White backgroundMixed / Multiple ethnic groups - White and Black CaribbeanMixed / Multiple ethnic groups - White and Black AfricanMixed / Multiple ethnic groups - White and AsianMixed / Multiple ethnic groups - Any other Mixed / Multiple ethnic backgroundAsian / Asian British - IndianAsian / Asian British - PakistaniAsian / Asian British - BangladeshiAsian / Asian British - ChineseAsian / Asian British - Any other Asian backgroundBlack / African / Caribbean / Black British - AfricanBlack / African / Caribbean / Black British - CaribbeanBlack / African / Caribbean / Black British - Any other Black / African / Caribbean backgroundPrefer not to sayDate of last dental visit When did you last have a dental visitWhere did you learn about the practice? Leaflet/Advert Passing by Internet Recommended by friend/family member ? Other Their name/relationship to youWould you like us to see any of your friends or family also: Yes No Name(s):NamePhone Number Add RemoveWould you like to be seen within the NHS (may be a waiting list) or PRIVATE outside of the nhs (earlier availability, finest materials, cosmetic treatments etc? PRIVATE NHS (Excludes cosmetic treatments) COVID-19Do you or anyone in your household have COVID-19?* Yes No Do you have a new, continuous cough?* Yes No Do you have a high temperature (37.8 degrees or over)?* Yes No Do you have a loss of, or change in, your normal sense of taste or smell?* Yes No Does anyone in your household have a new, continuous cough, or a high temperature, or a loss of, or change in, their normal sense of taste of smell?* Yes No If you or anyone in your household has, or has had, possible or confirmed COVID - 19, are you still in the self/household isolation period?* Yes No IF YOU HAVE RESPONDED POSITIVELY TO ANY OF THESE SYMPTOMS WE WOULD STRONGLY ADVISE SELF ISOLATING AND DELAYING NON-ESSENTIAL CARE FOR AT LEAST ONE MONTH. IF YOU HAVE A DENTAL EMERGENCY PLEASE CONTACT THE PRACTICE ON INFO@dentalimplantcentre.com SO THAT WE MAY MAKE SPECIAL ARRANGEMENTS FOR YOUR EMERGENCY CARE. Consent - COVID-19* Please tick to confirm the information is correct & Sign belowSignature - COVID-19*Your NameYour NameYour NameYour NameDate of Signature What dental treatment(s) are you interested in New Patient Examination Dental Implants Replace All Teeth Replace Loose Dentures Braces Smile Makeover Teeth Whitening Hygienist Pain/Emergency Facial Aesthetics Other I wish to register as a patient with a dentist at Dental Implant Centres @ Twyford Dental I understand and agree the following That the agreement by which I will be given dental treatment is an arrangement between the dentist and myself. That, under my treatment plan, my treatment will have to be paid for in total by the last visit. That, under my treatment plan; I may be required to pay in advance for certain items of treatment. That, under my treatment plan, I may be charged a fee of £10 for each 10 minutes of an appointment missed or cancelled without 48 hours prior notice. SignatureYour NameYour NameYour NameYour NameDate Doctors surgeryDoctors name Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Doctors Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Are youReceiving treatment from a doctor, hospital, clinic or a specialist? Yes No If Yes, give informationTaking any medicines or tablets (creams, ointments, injections)? Yes No If Yes, give informationTaking or have taken steroids in the last two years? Yes No If Yes, give informationHave YouHad rheumatic fever or chorea? Yes No If Yes, give informationHad jaundice, liver disease or hepatitis? Yes No If Yes, give informationEver been told you have a heart murmur or heart problems, angina or heart attack? Yes No If Yes, give informationHigh or Low Blood Pressure? If yes, do you know what it is? Date last taken? Yes No If Yes, give informationHad any blood tests? If so what for? Yes No If Yes, give informationEver had your blood refused by the blood transfusion service? Yes No If Yes, give informationEver had a reaction to a general or local anesthetic? Yes No If Yes, give informationHad a joint replacement? Yes No If Yes, give informationBeen hospitalized? If so what for? Yes No If Yes, give informationDo youHave arthritis or joint problems / osteoporosis? Yes No If Yes, give informationHave a pacemaker, or have you had any heart surgery? Yes No If Yes, give informationSuffer from hayfever, eczema or any other allergy? Yes No If Yes, give informationSuffer from bronchitis, asthma or any chest conditions? Yes No If Yes, give informationHave fainting attacks, blackouts or epilepsy? Yes No If Yes, give informationHave diabetes or does any one in your family? Yes No If Yes, give informationHave any bleeding disorders? Yes No If Yes, give informationCarry a warning card? Yes No If Yes, give informationEver get cold sores? Yes No If Yes, give informationEver Smoke? Yes No If Yes: Current Ex- Smoker How many a day?Drink Alcohol? Yes No How many units a week? (1 unit = ½ pint beer, 1 glass wine, 1 measure of spirit)Take any of the following medicines below?Antibiotics Yes No Diuretics Yes No Antidepressants Yes No Insulin Yes No Anticoagulants Yes No INR? E.g. WarfarinSteroids Yes No Antihistamines Yes No Hormones Yes No Blood pressure Tablets Yes No Tranquillizers Yes No Aspirin Yes No Bisphosphonates Yes No eg. FosomaxAny other medicines/Further information?Females OnlyAre you pregnant? Yes No Do you take oral contraceptives Yes No Have you had a hysterectomy Yes No Are you past the menopause Yes No Any other aspect of your health your dentist should know about?I consent to my General Medical Practitioner to be contacted for further medical information if and when required I have disclosed all relevant medical conditions SignatureYour NameYour NameYour NameYour NameDate Completed by: Self Parent Guardian Other SignatureYour NameYour NameYour NameYour Name Please return back to a member of staff. Thank youOffice use onlySignatureYour NameYour NameYour NameYour NameDentist Name First Last Date
