New Patient Name : Ms Miss Master Mr Mrs Address : Town : Postcode : Home phone no : Mobile no : Email : D.O.B : Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Gender : Male Female Paying Type : Paying Exempt Special Request : Cosmetic Treatments : Select Invisalign Implants Facial Rejuvenation Endodontics Smile Makeover None Where did you hear about us : Select Family Friends Web Leaflet Outside Sign Magazine adverts Yellow Pages Others I confirm that the contact details above are correct & that I prefer to be contacted by Bluebell Dental Practice by the following method's Following method's of communication Home phone : Mobile : Text/SMS message : Email : Letter by post : I authorise Bluebell Dental Practice to leave a message for me on the following telephone number I authorise Bluebell Dental Practice to communicate with my Husband/Wife/Partner/Parent/Carer. Name : Relationship : Permitted use of personal data (please select either clause A or B): A) In the event that any person working at Bluebell Dental Practice wishes to use any of my personal data for use for marketing, promotional, educational, training or any other purpose than my care & treatment, I permit the practice management to make an information request to me using the following method: (specify how to be contacted here: B) I DO NOT permit the practice management to request using my personal data for any purpose other than my care & treatment. Note: ‘Manufacturer guidelines state that the maximum weight that our dental chairs can hold is 120kg. Please speak to reception if you have any queries regarding this and we may be able to refer you to our local community care centre in Hainault.’
