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.

Title
MrMrsMissMs

Do you have dental insurance?
YesNo

Do you smoke?
YesNo

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?
YesNo

Have you ever been told you have a heart problem, Angina, raised blood pressure, heart attack or heart murmur?
YesNo

Do you have a pacemaker, or have you had any form of heart surgery?
YesNo

Do you have diabetes?
YesNo

Have you had jaundice, hepatitis or any other liver or kidney disease?
YesNo

Do you bruise easily or have you suffered from excessive bruising following an injury or any form of surgery or tooth extraction?
YesNo

Have you suffered any complications during or after a tooth extraction; e.g. difficult extraction, infection?
YesNo

Do you have fainting attacks, giddiness, blackouts or epilepsy? *
YesNo

Do you suffer from any allergies to medicines, food or materials?
YesNo

Have you had a bad reaction to a general or local anaesthetic?
YesNo

Are you pregnant?
YesNo

Are there any other aspects concerning your health that you think the dentist should know about?
YesNo

Are you taking any medicines prescribed by your doctor or of your own accord?
YesNo

Do you have any infectious diseases (e.g. TB, HIV or Hepatitis)?
YesNo

Completed by:
SelfParentGuardian

I undertake to settle all fees when due either at the time of treatment or in advance. Understand that interest may be paid of overdue accounts and that seriously overdue accounts may incur extra fees. If treatment is to be paid by a third party, i.e. under insurance or under Guernsey Social Security, I remain liable for those fees until the account is settled.
I Agree

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:

Stefan Cloete,
Principal Dentist,
scloete71@gmail.com