Please complete the online submission form below. You will only be registered once you have attended as a patient and been examined by one of the dentists.

Name *
Please consider these statements carefully and select your response
I’m concerned about the appearance of my teeth *
I’m interested in tooth whitening treatments *
I’m interested in fixed / removable aligner treatments *
I would like to discuss the shape of one or more of my teeth *
I have old fillings and would like to replace them with white fillings *
I have had previous dental treatment that is no longer satisfactory *
I wish to discuss anti-wrinkle treatments/ dermal fillers *
I wish to discuss options to fill gaps (i.e. dentures, bridges, implants) *

Please print, complete and sign this medical history form prior to attending your appointment.

It will avoid unnecessary delays when you attend your appointment.