Adult Registration Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 3Title *ie Mr, Mrs, Miss, Dr, MsFull Name *Full Address (including post code) *Date of Birth *Mobile Number *Email AddressHealth & Social Care Number *We need this number to register you as an NHS patient. This number can be obtained from your GP.Do you pay for your NHS Treatment? *Yes, I payNo, I receive an Exemption BenefitNo, I am currently PregnantNo, I have had a baby in the past 12 monthsNo, I am 18 and in Full Time EducationSpecify your Exemption Benefit belowPlease specify which Benefit you receive *I, or my Partner, receive Pension Credit GuaranteeI, or my Partner, receive Job Seekers AllowanceI, or my Partner, receive Income SupportI am named on a valid NHS Tax Credit CertificateI am named on a valid HC2 CertificateI am named on a valid HC3 CertificateI receive Employment & Support AllowanceNONE OF THE ABOVEPlease bring proof of your benefit to your appointmentDo you require a ground floor surgery? *YesNoNextConfidential Medical History We ask for information about your general health to help treat you safely. All information will be strictly confidential. Please fully complete the form below. Your OccupationDoctor's NameDoctor's Surgery *Next of Kin Name *Next of Kin Contact Number *Do you have any Allergies to the following: *Medication (eg Penicillin)Materials (eg Latex, Rubber)Food (eg Nuts)NONE OF THE ABOVEFurther Information If you have selected any of the boxes above, please provide further information as appropriateHave you ever had: *I have a Heart Condition (Angina/High Blood Pressure/Heart Attack)I’ve had a StrokeI have Bone and/or Joint Disease (eg Arthritis/Osteoporosis)I have Liver/Kidney Failure, Jaundice or HepatitisNONE OF THE ABOVEPlease select multiple boxes if applicableAre you taking any medication from your doctor? *YesNoIf yes, please list your medication or upload a photo belowMedication List *If no medication is applicable, simply input N/AUpload a photo of your Medication List Click or drag a file to this area to upload. Are you: *I am receiving Hospital Treatment from a SpecialistI am Pregnant or possibly PregnantI am taking Hydrocortisone or CorticosteroidsNONE OF THE ABOVEPlease select multiple boxes if appropriateFurther InformationIf you have selected any of the boxes above, please provide further information as appropriateNextDo you: *I have a PacemakerI suffer from Asthma and/or Chronic BronchitisI have DiabetesI suffer from Epilepsy or Fainting AttacksI Bruise or Bleed easilyI carry a Medical Warning CardI have an Infectious Disease (eg HIV or Hepatitis)I suffer from another serious illnessNONE OF THE ABOVEPlease select multiple boxes if appropriateFurther Information If you have selected any of the boxes above, please provide further information as appropriateDo you drink Alcohol? *YesNoIf yes, specify the units of Alcohol per week? Selected Value: 0 For example, 14 units is equivalent to 6 pints of average-strength beer or 10 small glasses of lower-strength wine.Do you smoke any Tobacco products? *YesNoIf yes, specify the amount per day: Selected Value: 0 Updating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Accept Terms *Yes I am happyI confirm that the above information is true and accurate to the best of my knowledge. We hold and maintain patient information that is necessary for the effective provision of dental care. All information will be held in the strictest confidence.PreviousSubmit
