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