To download the printable form click here.
We will send you email communications from time to time, including appointment reminders. Please tick this box if you do not wish to receive email communication from us.
Have there been any changes to the following? If so, please tick the appropriate boxes.
Are you suffering from any of the following?
On a scale of 1 – 10, with 10 being very comfortable and not at all anxious, how comfortable are you feeling about your appointment today?
I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and
I assume full financial responsibility for said treatment.