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Skin Clinic
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Cymraeg

Maes-Y-Coed Road

Cardiff, Wales, CF14 4HE

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Home
About Us
Sign up
News
Skin Clinic
Dental Plan
Contact
Cymraeg

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.

Title *

Name *

Name

First Name

Last Name

Date of Birth *

Address *

City *

Postcode *

Home Phone Number *

Mobile Number

Email Address *

Please consider these statements carefully and select your response

I’m concerned about the appearance of my teeth *

Yes

I’m interested in tooth whitening treatments *

Yes

I’m interested in fixed / removable aligner treatments *

Yes

I would like to discuss the shape of one or more of my teeth *

Yes

I have old fillings and would like to replace them with white fillings *

Yes

I have had previous dental treatment that is no longer satisfactory *

Yes

I wish to discuss anti-wrinkle treatments/ dermal fillers *

Yes

I wish to discuss options to fill gaps (i.e. dentures, bridges, implants) *

Yes

Please use the space below to write anything you would like to discuss with your dentist: *

Thank you!

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

It will avoid unnecessary delays when you attend your appointment.

590 Tahoe Keys Blvd, South Lake Tahoe, CA 96150

Gwena Dental Care
1st Floor Lancaster House
106 Maes-y-Coed Road
Cardiff CF14 4HE

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029 2061 5279