Register Online — New Patients | Chester Road Dental Care, Poynton

About you

Tell us who you are. Fields marked * are required.

Who is completing this form?

Myself Parent (for my child) Guardian

Patient details

Title

First name * Please enter a first name

Last name * Please enter a last name

Date of birth * Please enter a date of birth

Female Male

Please choose an option

Address * Please enter your address

Postcode * Please enter your postcode

Occupation / school

Ethnic group — helps us monitor equality of care

Contact, emergency & doctor

How can we reach you — and who should we contact if we ever can't?

Your contact details

Mobile number * — used to confirm appointments Please enter a contact number

Telephone number (home)

Email * Please enter a valid email address

Text / SMS Email Phone Mail

You will only ever receive communication from Chester Road Dental Care.

Emergency contact — during a medical emergency where you're unable to speak for yourself, you give permission for staff to contact:

Name

Telephone number

Relationship to you

Doctor's details

Doctor's name / practice

Telephone number

Address

Postcode

Are you currently…

Answer yes or no to each — a details box appears when we need a little more.

Receiving treatment from a doctor, hospital or clinic?

Yes No

Taking any prescribed medicines?e.g. tablets, ointments, injections or inhalers, including contraceptives and hormone replacement therapy

Yes No

Carrying a medical warning card?e.g. yellow book, pacemaker, anticoagulant, bisphosphonates

Yes No

Pregnant or possibly pregnant?

Yes No N/A

Number of weeks

Have you ever had…

These help us treat you safely. Answer yes or no to each.

Allergies to medicines, substances or foods?e.g. penicillin, latex/rubber

Yes No

Bronchitis, asthma or other chest condition?

Yes No

Fainting attacks, giddiness, blackouts or epilepsy?

Yes No

Heart problems, angina, blood pressure problems, or stroke?

Yes No

Diabetes — or does anyone in your family?

Yes No

Bone or joint disease?

Yes No

Bruising or persistent bleeding following injury, tooth extraction or surgery?

Yes No

Liver disease (e.g. jaundice, hepatitis) or kidney disease?

Yes No

Any other serious illness or infectious disease?

Yes No

Blood refused by the Blood Transfusion Service?

Yes No

A bad reaction to general or local anaesthetic?

Yes No

Treatment that required you to be in hospital?

Yes No

Heart surgery?

Yes No

Lifestyle & anything else

No judgement here — these simply help us give you the best preventative advice.

Alcohol

How many units of alcohol do you drink per week? — a unit is half a pint of lager, a single measure of spirits or a single glass of wine

Smoking

Do you smoke any tobacco products now — or did you in the past?

Yes In the past No

Times per day

Do you chew tobacco, pan, use gutkha or supari now — or did you in the past?

Yes In the past No

Times per day

Habits

High sugar frequency

Yes In the past No

Lots of fizzy / acidic drinks

Yes In the past No

Recreational drugs

Yes In the past No

Anything else your dentist should know?

Other details — such as self-prescribed medicines (e.g. aspirin) or any disabilities you may have

Are you interested in your dentist discussing…

Tooth whitening Orthodontics Something else

Please specify

Check your answers

Review everything below. You can edit any section before finishing.

Declaration

I confirm that the information I have given is correct to the best of my knowledge, and I understand it will be used by the dental team at Chester Road Dental Care to care for me (or the child I am responsible for) safely. I will tell the practice about any changes to my general health. * Please confirm the declaration to continue

Type your full name as your signature * Please type your full name

Date

All done — thank you!

Your form is complete and saved on this device. To finish your registration, choose one of the options below — then call us on 01625 876900 to book your first examination.

Print it and bring it to your first appointment, save it as a PDF and email it to info@chesterroaddentalcare.co.uk, or simply bring your phone — we can take it from there.

Confidential patient registration & medical history

About you

Contact, emergency & doctor

Are you currently…

Have you ever had…

Lifestyle & anything else

Check your answers

All done — thank you!