Hartog at
Alresford
Hartog at
Botley
Hartog at
Twyford
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Traditional Dentistry
Oral Hygiene and Hygienists
Children’s Dentistry
Root Canals / Endodontics
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Referred to Hartog Dental?
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Home
:
New
New
New patient page with forms.
New Patient Form
Welcome to Hartog Dental. Please complete the following confidential information to help us care for you in the best possible way. Thank you.
NAME
*
Title
First Name(s)
Surname
DATE OF BIRTH
*
EMAIL
HOME ADDRESS
*
MOBILE NUMBER
HOME TELEPHONE NUMBER
*
OCCUPATION
MEANS OF TRAVEL TO DENTIST
PREFERRED METHOD OF RECEIVING APPOINTMENT REMINDERS
Post
Text Message
Email
HOW DID YOU HEAR ABOUT US?
Website
Google or other search engine
Leaflet
Recommendation
Sign / Poster
IF BY RECOMMENDATION, LET US KNOW WHO, WE'D LIKE TO SAY THANK YOU!
How Can We Help You?
WHAT ARE YOUR MAIN AIMS FOR DENTAL TREATMENT?
LAST DENTAL EXAMINATION DATE
Day
Month
Year
NAME AND ADDRESS OF LAST DENTIST (inc. POSTCODE)
DO YOU FLOSS?
Yes
No
FAMILY HISTORY (DIABETES, MISSING TEETH? etc)
DIET - SUGAR IN HOT DRINKS?
HOW DO YOU FEEL ABOUT YOUR TEETH IN GENERAL?
HAVE YOU HAD OR DO YOU HAVE PROBLEMS WITH ANY OF THE FOLLOWING? (SELECT ALL THAT APPLY)
Chewing
Speech
Food catching between teeth
Swelling or lumps in mouth
Mouth ulcers
Sensitivity to heat
Sensitivity to cold
Sensitivity to sweet things
Bleeding gums
Sensitivity to pressure
Clenching or grinding habits
Crowded or mal-positioned teeth
Had orthodontic treatment
Jaw clenching
Missing teeth
Wisdom teeth
How your teeth look
Do you play contact sports
Loose teeth
Bad taste
Mouth ordour
Smoking
Colour
Shape
Size
Gaps
DOES ANY PART OF DENTAL TREATMENT MAKE YOU FEEL NERVOUS OR ANXIOUS?
CAPTCHA
Hartog at Botley
Hartog at Botley
21 High Street
Botley, SO30 2EA
01489 781 955
botley@hartogdental.co.uk
Hartog at Alresford
Hartog at Alresford
4 Pound Hill
Alresford, SO24 9BW
01962 733 580
alresford@hartogdental.co.uk
Hartog at Twyford
Hartog at Twyford
The Old Fire Station, Hazeley Road
Twyford, Winchester, SO21 1PT
01962 714 459
twyford@hartogdental.co.uk
Home
Dental Services / Treatments
Traditional Dentistry
Oral Hygiene and Hygienists
Orthodontic Services
Invisalign (Clear Braces)
Root Canals / Endodontics
Sedation For Nervous Patients
Children’s Dentistry
Emergencies
Somnowell
Teeth Whitening
Gumshields
Weekend & Evening Appointments
Referred to Hartog Dental?
Dental Implants
Facial Aesthetics
The Hartog Dental Team
About us
Overview
Testimonials
The Hartog Blog
FAQS
Fees
Contact
Overview
Hartog at Alresford
Hartog at Botley
Hartog at Twyford
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Existing Patients
Referrals
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