New Patient Questionnaire

Patient name:

Dob

Occupation:

Dear Patient,

At GK Dental, we would like to take the time to understand how to treat you in the way you want. The questions below are designed to help us provide a service tailored to you.

PREVIOUS DENTAL EXPERIENCE:

When was the last time you visited the dentist?

Are you currently in any dental pain? If yes, please elaborate

Is there a specific treatment you would like? Eg. Whitening/Invisalign etc

Do your gums bleed when you brush or floss?

Yes No

Do you think you might clench or grind your teeth?

Yes No

Do you believe you have bad breath or an unpleasant taste in your mouth?

Yes No

Do you have dental insurance?

Prefer not to say Yes No

WE HIGHLY RECOMMEND OUR PATIENTS TO HAVE REGULAR HYGIENE APPOINTMENTS TO PREVENT GUM DISEASE AND OTHER DENTAL PROBLEMS.

Would you be interested in receiving a private tailored hygiene programme?

Yes No

TREATMENTS FOR YOU:

Please tick any of the treatments that may interest you:

What is more important to you:

Price Level of service Appointment availability Running on time

How did you hear about us?

Word of mouth Passing by Google/Social media Other

PLEASE NOTE:

TO PROVIDE THE BEST SERVICE POSSIBLE TO OUR PATIENTS WE OPERATE ON A STRICT 48 HOUR CANCELLATION POLICY. PATIENTS THAT LATE CANCEL OR FAIL TO ATTEND WILL BE CHARGED AND POSSIBLY DEREGISTERED FROM THE PRACTICE.
We require all balances to be cleared at each appointment in order to operate at a high level

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GK Dental Hawick is a reputed Dental Care Excellence, With delivering top-notch NHS dentist in Hawick and private cosmetic dentistry, we proudly serve the community of Hawick.

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New Patient Questionnaire