Dentist in Pinner, Middlesex

Call us for a consultation today
020 8866 8512

First Floor   37 Love Lane   Pinner   Middlesex   HA5 3EE

New Private Patient Registration

Please email us at or use the online form below.
Fields in bold are required.

Phone Number
Date of Birth
Are you under treatment from your doctor, the hospital or clinic?
Do you wear a pace maker?
Have you ever had:  
Heart complaints? Yes No Rheumatic Fever? Yes No
Heart Murmur? Yes No High or Low blood pressure? Yes No
Hepatitis, Jaundice, liver or kidney complaints?
Epilepsy, fainting attacks, fits?
Diabetes or sugar problems?
Abnormal bleeding after extraction's, surgery or injury
Problems after a general or local anaesthetic?
Are you allergic to penicillin, other medicines or tablets?
Are you expecting or nursing a baby?
Are you taking any medicines, pills or tablets?
Have you had any operations?
Do you suffer from HIV or AIDS?
Do you smoke? Yes No
What quantity?
Is there anything else that would be valuable for us to know?
When last did you have a comprehensive Dental Examination?
Did you have X-rays? Yes No
How often did you visit the Dentist before then?
Who recommended you to our Practice?
Why did you want to change Dental Practices?
Do you have any fears or worries about Dental Treatment?
Do you have any Jaw pain / clicking while eating?
Are you aware or grinding your teeth while sleeping or under stress?
Do you suffer from any ear or eye problems?
Do you have any concerns about your teeth and gums?
Do your gums bleed? Yes No If yes, when do they bleed?
Are you aware of any broken or painful teeth?
Is there anything about your teeth you want to change?
Are you happy with the colour of your teeth?
Are you concerned about Mercury in your fillings?
Are you aware of any mouth odour? If so, when?
Is there anything you wish to add?
I consent to my personal data being collected and stored as per the Privacy Policy.
I consent to my personal data being collected and stored for the purpose of marketing communications.
To prevent spam using our form, please enter the characters as shown in the image opposite.
Copyright © Pinn Dental Practice. All Rights Reserved.
Dentist in Pinner, Middlesex
Last Update: 14-Nov-2019
Cosmetic Dentistry Pinner – We welcome the new dental patient at dentistry in Pinner .