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New Patients

Medical History Form Download

If you are attending our practice for the first time, we will ask to to fill out a medical history form. Save time by completing it at home! After downloading the document below, please print out and complete the form before bringing it with you to the first appointment. If you don't understand any part of it, leave that section blank, and we will help you to complete it when you attend.

Southgate Smiles Medical History Form PDF Download (1 MB approx.)

Private Patients Registration Form

Title *


Surname *

First Name(s) *

Address 1 *

Address 2 *

Post Code *

Home Telephone *

Work Telephone

Mobile Telephone

Email Address *

Date Of Birth *

Any Other Information

Code Verification*

We will call you back to arrange an appointment for your initial examination.