If you choose, fill in the form below to register as a patient. All fields are required unless it states otherwise. If you prefer, you can print off this form and bring in to our reception.
After the form has been completed, please contact us to book an appointment or you can book your appointment online.
Any information entered or sent via web forms on this website will be securely and fairly processed by Queens Road Dental Centre under the Data Protection (Bailiwick of Guernsey) Law, 2001.
If you have any queries regarding this, please contact: