The family dentist with in house specialist team

New patients registration form

Please fill out the following form to help us contact you. If we are aware of your particular concerns we can ensure that there is time to discuss them at your appointment.

Alternatively, you can print out this form by clicking on this link. You can fill in the printed copy and bring it with you when you next visit the surgery, or send it to our postal address: Granta Dental, The Old Coach House, 53 Newnham Road, Cambridge, CB3 9EY.

Your name
Your address
Your postcode
Daytime telephone
Evening telephone
Mobile phone
Email address
Date of birth
How can we help you?
How do you prefer to be contacted?
Appointments are available weekdays, what time suits you best?
Do you require disabled car parking for appointments?
Do you require wheelchair access?
Do you find stairs difficult?
Other special requirements?
Are you concerned with the appearance of your teeth and smile?
Are you worried by the colour of your teeth, crowns or fillings?
Are you worried that your breath smells?
Are your teeth sensitive?
Are you worried by gaps that show?
Do your dentures feel uncomfortable?
Are you concerned about the cost of treatment?
Do your gums bleed when you brush your teeth?
Do you experience frequent headaches, pain or stiff neck?
How did you hear about us?