New patient form

To ensure we have all the information we need for your first visit, please fill out the appropriate health history form below and bring this with you on the day.

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Patient Information

Billing Information

Medical Information

I have completed this Questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place ME at undue risk. I understand that notes, radiographs (xrays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send appointment and check up reminders.

By clicking ‘Submit’ you are agreeing to our privacy policy.

Book a free consultation!

No-obligation initial meeting with our Specialist Orthodontist Dr Kataria to discuss your options.

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