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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:


    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?


    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?

    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?

    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?

    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: