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

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



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