Online Booking – New Patients

If you are a new patient to Bow Lane Dental Group please complete the following form. If you do not wish to book online please call us on 020 7236 3600 to arrange your first appointment and complete this form for your first assessment. If you are an existing patient please click here.

Personal Information
Title
First Name
Surname
Phone
Email
Address
Post Code

Appointment Information
Date
Time

Other Information
Are you insured?  yes no
Date of Birth
Last Dental Visit

General Questions

Are you happy with your smile?  yes no
Would you like your teeth to look whiter or brighter?  yes no
Are your teeth sensitive?  yes no
Have you any teeth you think are unsightly, misshapen or out of line?  yes no
Are you concerned you may have bad breath or an unpleasant taste in your mouth?  yes no
Do your gums bleed when you're brushing or flossing?  yes no
Do you suffer from headaches/neck aches or shoulder pain?  yes no
Do you clench or grind your teeth?  yes no
Do you smoke?  yes no
Number of cigarettes per day:

Are You Concerned About?

Old crowns that now do not match your other teeth or have dark lines at the gum?  yes no
Old or stained fillings that show when you smile?  yes no
Silver fillings that you would like replacing with tooth coloured restorations so that they blend in better?  yes no
Any missing teeth that you would like to replace?  yes no

Are You?

Receiving treatment from a doctor, hospital or clinic  yes no
Taking any pills, medicines or tablets  yes no
Allergic or have you reacted adversely to:
a) Penicillin or any other drug or medicine  yes no
b) Latex or other materials  yes no
Taking any of the following:
a) Antibiotics  yes no
b) Anticoagulants  yes no
c) Medicine for high blood pressure  yes no
d) Cortisone (steroids)  yes no
e) Insulin or other medication for diabetes  yes no
f) Other  yes no

In The Past Have You?

Had any serious illness or operations?  yes no
Had any of the following diseases or problems:
a) Rheumatic fever or rheumatic heart disease  yes no
b) Heart trouble, replacement heart valve, high blood pressure or stroke  yes no
c) Sinus trouble  yes no
d) Asthma  yes no
e) Diabetes  yes no
f) Hepatitis or HIV  yes no
Had abnormal bleeding associated with previous extractions,surgery or trauma?  yes no
Had any problems with previous dental treatment?  yes no

Women Only

Is there any possibility that you may be pregnant?  yes no
Estimated date of delivery?

Additional Information

How did you hear about us