U18 Registration Form

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Full Name *

Full Address (including post code) *

Date of Birth *

Mobile Number *

Email Address

Relationship to Patient *

ie Parent or Legal Gaurdian

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 require a ground floor surgery? *

Confidential Medical History Form

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)
NONE OF THE ABOVE

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
NONE OF THE ABOVE

Please select multiple boxes if applicable

Are you taking any medication from your doctor? *

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

Medication List

If no mediacation is applicable, simply insert 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
NONE OF THE ABOVE

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
NONE OF THE ABOVE

Please select multiple boxes if appropriate

Further Information

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

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Accept Terms *

Yes I am happy

I hereby 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.