NHS Signup

We're a private and NHS dental practice with locations in Burton & Derby.

NHS Registration

    We hope you will be very satisfied with the care you receive in our practice. We would like to know what made you choose us. Were any of the following reasons involved?

    Medical history

    Diabetes

    YesNo

    Arthritis

    YesNo

    Epilepsy, blackouts, giddiness or fainting

    YesNo

    Rheumatic Fever

    YesNo

    Chronic Bronchitis, Asthma or any other Respiratory Disease

    YesNo

    Hepatitis, Jaundice, Liver or Kidney Disease

    YesNo

    High blood pressure or Angina

    YesNo

    Heart Disease, Heart Attack or any related complaints

    YesNo

    Has had Heart/Pace-maker surgery

    YesNo

    Steroid Therapy has been administered in past two years

    YesNo

    Persistent mouth ulcer lasting more than 3 weeks

    YesNo

    HIV Positive

    YesNo

    Any Allergies

    YesNo

    Ever had allergic reactions to Local or General Anaesthetic

    YesNo

    Recently undergone any blood tests

    YesNo

    Excessive bleeding and/or bleeding disorders

    YesNo

    Are you pregnant or have had a baby in the last 12 months

    YesNo

    Undergone a joint replacement operation

    YesNo

    Are you currently undergoing any Medical Treatment

    YesNo

    At present undertaking medication

    YesNo

    Undergone hospitalisation that may affect dental care

    YesNo

    Any other serious illness or related medical condition

    YesNo

    If you smoke, how many per day
    What is average weekly consumption of alcohol
    Please list any medication you are taking