BEECHWOOD DENTAL NEW PATIENT QUESTIONNAIRE Please enable JavaScript in your browser to complete this form.Thank you for choosing Beechwood Dental. We have built our reputation by providing our patients with professional, courteous and stress-free dental care. To help us do that, we kindly ask you to complete the questionnaire below. Some questions are related to your general medical health & history, and some relate to your dental needs, concerns and expectations.PERSONAL DETAILSThe information your provide in this form will be stored in accordance with the privacy principles of the General Data Protection Regulation (GDPR). Name *FirstLastAddress *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEmail *Mobile Phone *Home or Work PhonePPS # *OccupationPatient Type (Private / PRSI) *Your GP name and address *MEDICAL HISTORYThe information your provide in this form will be stored in accordance with the privacy principles of the General Data Protection Regulation (GDPR). Are you seeing your Doctor for any medical condition or do you take prescription medication? *YesNoDo you suffer from any of the following: *DiabetesBleeding ConditionCancerHeart DiseaseBreathing DifficultiesAsthmaVertigoOsteoporosisHeart murmur or had heart surgeryAre you pregnant? *YesNoDo you smoke? *YesNoGENERAL QUESTIONNAIREWhat would you like to discuss with your dentist today? *Check UpEmergency or pain reliefStraightening teethReplacing missing teeth (Dentures/Bridges/Implants)Cosmetic DentistryDental Hygienist visitOtherOther reason for visit:How did you hear about Beechwood Dental? *Live in the areaOnline/Google SearchWord of mouthSocial MediaDo you attend a dental hygienist? YesNoI'd like to know moreIs there anything in particular that makes you nervous about dental treatment?Past experienceInjectionsOtherOther reasonDEPARTMENT OF SOCIAL PROTECTION: I authorise Beechwood Dental to use my personal data for the purpose of checking my eligibility for Treatment Benefits and to allow for the processing of the payment claim in respect of treatments I have received. I understand that I may revoke this consent at any time by contacting the Department. *YesNo I consent to receive SMS appointment reminders *YesNoI consent to receive occasional news or updates on new services at Beechwood Dental by email *YesNoI have read and understand Beechwood Dental's Privacy Statement *YesThank you for your time. If there are any points which have not been covered by our questionnaire, and you would like to mention them, please do so below. We appreciate your time and patience - your answers are used to help us provide a better service to you and other patients.Submit
