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Quick Enquiry

We are looking forward to seeing you at The Hampton Wick Dental Centre

Before attending the Centre for the first time, please fill in the Personal Dental Assessment form (online below), or click here to download a printable pdf, or alternatively, arrive 10 minutes early for your appointment and do so in reception. Please bring with you a list of medication that you are on and any health insurance claim forms.

We offer practice tours and if you would like a tour of our practice, please arrive 15 minutes earlier and we will be happy to show you around.

It is important for the smooth running of the practice that you arrive for your appointment in plenty of time. We appreciate that on occasions events can happen which may make you late for an appointment, in these situations if you can ring and advise the reception team so that provisions can be made.

If you are unable to make your dental appointment for any reason, please let us know at least 24 hours ahead of the appointment time or a charge may be incurred for the lost surgery time. In this way we can ensure that we use the valuable time for waiting patients.

On line personal assessment form

Fields marked with an * are required.

If you are attending The Hampton Wick Dental Centre for the first time, please complete this online form.





Personal Details:

Title

Name *

Date of birth

Home address *

Mobile number*

Home telephone

Work telephone *

Email *

Business Details

Business address

Business telephone

Business email

Dental History

When was your last dental examination?

How did you hear about The Hampton Wick Dental Centre?

Do you have dental insurance?

YesNo

About You

Are you happy with your smile? YesNo

Would you like your teeth to look whiter or brighter? YesNo

Are your teeth sensitive? YesNo

Do you have any teeth you think are unsightly, misshapen or out of line? YesNo

Are you concerned you may have bad breath or an unpleasant taste in your mouth?
YesNo

Do your gums bleed when you brush or floss? YesNo

Do you suffer from headaches, neck aches or shoulder pain? YesNo

Do you clench or grind your teeth? YesNo

Do you smoke ? YesNo

How many a day? 1-1010-2020-3030+

Are you concerned about

Old crowns that do not match your other teeth or have dark lines at the gum?
YesNo

Old or stained fillings that show when you smile? YesNo

Silver fillings that you would like to replace with tooth coloured ones? YesNo

Any missing teeth that you would like to replace? YesNo

Are you…

Fit and healthy? YesNo

Receiving treatment from a doctor, hospital or clinic? YesNo

Taking any pills, medicines or tablets? YesNo

Allergic or have reacted adversely to:

Penicillin or any other drug or medicine? YesNo

Latex, rubber or other materials? YesNo

Costume jewellery or other metals? YesNo

Taking any of the following:

Antibiotics? YesNo

Anticoagulants? YesNo

Medicine for high blood pressure? YesNo

Cortisone or other steroids? YesNo

Insulin or other diabetes medication? YesNo

Tablets for Osteoporosis (biphosphorates)? YesNo

Other medication YesNo

In the past, have you …

Had any serious illnesses? YesNo

Had any of the following diseases or problems:

Rheumatic fever or rheumatic heart disease? YesNo

Heart trouble, replacement heart valve, high blood pressure or stroke?
YesNo

Sinus trouble? YesNo

Asthma or respiratory diseases? YesNo

Diabetes? YesNo

Hepatitis or HIV? YesNo

Had abnormal bleeding associated with previous extractions, surgery or trauma? YesNo

Had any problems with previous dental treatment? YesNo

Women patients only …

Is there any possibility that you may be pregnant? YesNo

If so, what is the estimated date of delivery?

Final comments: