NHS Signup

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

NHS Registraton

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

DiabetesYesNo
ArthritisYesNo
Epilepsy, blackouts, giddiness or faintingYesNo
Rheumatic FeverYesNo
Chronic Bronchitis, Asthma or any other Respiratory DiseaseYesNo
Hepatitis, Jaundice, Liver or Kidney DiseaseYesNo
High blood pressure or AnginaYesNo
Heart Disease, Heart Attack or any related complaintsYesNo
Has had Heart/Pace-maker surgeryYesNo
Steroid Therapy has been administered in past two yearsYesNo
Persistent mouth ulcer lasting more than 3 weeksYesNo
HIV PositiveYesNo
Any AllergiesYesNo
Ever had allergic reactions to Local or General AnaestheticYesNo
Recently undergone any blood testsYesNo
Excessive bleeding and/or bleeding disordersYesNo
Are you pregnant or have had a baby in the last 12 monthsYesNo
Undergone a joint replacement operationYesNo
Are you currently undergoing any Medical TreatmentYesNo
At present undertaking medicationYesNo
Undergone hospitalisation that may affect dental careYesNo
Any other serious illness or related medical conditionYesNo




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



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