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DATE OF COMPLETING FORM…………………… REQUEST FOR DENTAL TREATMENT AT ALPHA DENTAL GROUP FORM NUMBER…… TITLE ………. FIRST NAME(S)…………………………………………………………….. SURNAME………………………………………………………………………………………….. DATE OF BIRTH ……./………/………….. ADDRESS……………………………………………………………………………………………. …………………………………………………………………………………………………………… …………………………………………………………………………………………………………….. POSTCODE……………………………… HOME TEL NUMBER…………………………………………………………….. WORK TELEPHONE NUMBER ……………………………………………… MOBILE NUMBER………………………………………………………………… EMAIL ADDRESS ………………………………………………………………….. OCCUPATION……………………………………………………………………….. PARENT/GUARDIAN NAME ( for children under 16) ………………………………………………. When did you last receive dental treatment? Less than 6 months 6 months – 1 year 1-2 years More than 2 years Who did you see last for dental treatment…………………………………………………….. Are you on a PCT/NHS waiting list for a place in a NHS practice YES/NO Do you need urgent dental treatment ( you are experiencing pain)? YES/NO If Yes give brief detail of problem…………………………………………………………………… ……………………………………………………………………………………………………………………… Are you wanting to register as a NHS patient ( YES/NO) Please circle your preferred day /time for appointment Do you have a preferred dentist you would like to see at Alpha……………………………. Mon Tues Wed Thurs Fri Sat 8am-10am 10am – 4pm 4pm – 6pm Please indicate when you would like an examination appointment As soon as possible or Month………….Year…………….. Please circle any of the following treatment which you are interested in Tooth Whitening Cosmetic treatment Orthodontic treatment Invisalign Implants Botox treatment sedation Routine treatment Please complete one form per family member - please list names of other family members you are registering who live at the same address………………………………………………………………. ……………………………………………………………………………………………………………………………… …………. ……………………………………………………………………………………………………………………………… ………… PLEASE NOTE ALPHA DENTAL GROUP WILL NOT OFFER REPEAT APPOINTMENTS TO PATIENTS WHO FAIL TO KEEP THEIR APPOINTMENTS FOR DENTAL TREATMENT
