EmailMe Form - The Richmond Dentist Registration Form

Welcome to our practice ! Please be as thorough as possible in filling out this form as this will help us to serve you better. Please be assured that this form is strictly private and confidential and once completed is sent directly to my practice.
Thank you, and we look forward to seeing you soon!
Dr Hap Gill

Patient Registration and Medical History

Title *

Name *

First Last

Preferred Name

(first, last, Lord, Sir, Professor etc)

Gender *

Male

Female

Date of Birth

DD / MM / YYYY

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

Work Phone

Mobile

Email *

Preferred method of contact *

Phone

Email

Post

Employer

Profession

How did you hear about The Richmond Dentist?

If internet, what did you search for?

Getting to Know You

Why do you seek dental care now?

Whom can we thank for referring you?

Family

Friend

Coworker

How long since your last dental visit?

What was done?

Is there anything you would like to change about your smile, or any other part of your mouth? What would that be?

Please describe your long-term goals for the health of your mouth and teeth:

What dental services have you had?

Others

Have you postponed recommended treatment?

Yes

No

Tell me more about that:

Have you had problems or undesirable experiences with previous dental treatments?

Yes

No

What can we do to make you most comfortable?

Is there anything else you would like us to be aware of?

Yes

No

Please give details

Are you concerned by lines or wrinkles on your face?

Yes

No

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