Adult Registration Form

Title

ie Mr, Mrs, Miss, Dr, Ms

Full Name

Full Address

Post Code

Date of Birth

Mobile Number

Email Address

Health & 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 pay
No, I receive an Exemption Benefit
No, I am currently Pregnant
No, I have had a baby in the past 12 months
No, I am 18 and in Full Time Education

Specify your Exemption Benefit below

Are you entitled to Claim? For further info, follow the guidance by clicking on the link below:

Help With Dental Costs

Are you claiming Universal Credit? For further info, follow the guidance by clicking on the link below:

UC Help with Health Costs

Please specify which Benefit you receive

I, or my Partner, receive Pension Credit Guarantee
I, or my Partner, receive Job Seekers Allowance
I, or my Partner, receive Income Support
I am named on a valid NHS Tax Credit Certificate
I am named on a valid HC2 Certificate
I am named on a valid HC3 Certificate
I receive Employment & Support Allowance
NONE OF THE ABOVE

These are the only benefits that may cover your NHS Treatment. Please bring proof of your benefit to your appointment

Do you require a ground floor surgery?

Yes
No

Confidential 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.

Doctor's Name

Doctor'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)
I HAVE NO ALLERGIES

Further Information

If you have selected any of the boxes above, please provide further information as appropriate

Have you ever had:

I have a Heart Condition (Angina/High Blood Pressure/Heart Attack)
I’ve had a Stroke
I have Bone and/or Joint Disease (eg Arthritis/Osteoporosis)
I have Liver/Kidney Failure, Jaundice or Hepatitis
I HAVE NO HEALTH CONDITIONS

Please select multiple boxes if applicable

Are you taking any medication from your doctor?

Yes
No

If yes, please list your medication or upload a photo below

Medication List

If no medication is applicable, simply input N/A

Upload 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 Specialist
I am Pregnant or possibly Pregnant
I am taking Hydrocortisone or Corticosteroids
I AM NOT RECEIVING HOSPITAL TREATMENT

Please select multiple boxes if appropriate

Further Information

If you have selected any of the boxes above, please provide further information as appropriate

Do you:

I have a Pacemaker
I suffer from Asthma and/or Chronic Bronchitis
I have Diabetes
I suffer from Epilepsy or Fainting Attacks
I Bruise or Bleed easily
I carry a Medical Warning Card
I have an Infectious Disease (eg HIV or Hepatitis)
I suffer from another serious illness
I HAVE NO HEALTH CONDITIONS

Please select multiple boxes if appropriate

Further Information

If you have selected any of the boxes above, please provide further information as appropriate

Do you drink Alcohol?

Yes
No

If 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?

Yes
No

If yes, specify the amount per day:

Selected Value: 0

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I agree to adhere to the FTA Policy below

Yes I agree

Cathedral Quarter Dental employs a strict Failure to Attend and Short Notice Cancellation Policy in order to help accommodate the needs of our patients.

FTA Policy

Accept Terms

Yes I am happy

I 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. Please note you are not a fully registered patient until you have received your first examination.