Contact us - join us

To join the practice as a patient you can pop into our surgery and pick up a medical questionnaire form, or alternatively use our online form below and send it to us from this site!

Before we are able to examine you or provide any dental treatment, it would be appreciated if you could complete the following questionnaire. It is important for us to know of any medication you are taking, and any illnesses that you have or have had in case they could affect your dental health and proposed treatment.

The information that you give here will be used solely by the Orchard Dental Practice and will be treated with the utmost confidence. At no time will we pass any of this information on to third parties for marketing, research or any other activity.

Personal Details

 

Medical and Dental history

Are you currently...

 

Do you...

 

Have you ever...

 

Women...

 

Do you ever suffer pain when...

 

Do you have any other dental problems?