North Road, Lampeter, Ceredigion — SA48 7HZ 01570 422595 | Book Online

Register as a
new patient

Please complete all sections before your first appointment. Fields marked * are required.

01

Personal Details

Please enter your first name.
Please enter your surname.
Please enter your date of birth.
Please enter your address.
Please enter your postcode.
Please enter a valid email address.

02

Emergency Contact

03

Dental History & Anxiety

yearsmonths

04

Current Dental Concerns

Please indicate whether you currently experience any of the following.

Concern Yes No

05

Oral Hygiene & Lifestyle


06

Reason for Joining

Please tick all that apply.

07

Treatments of Interest

Please tick any treatments you would like to know more about.

08

Access & Communication

09

How Did You Hear About Us?

10

Privacy & Consent

How we use your information
Your personal information will be held securely by Pont Steffan Dental and used solely for the purposes of your dental care. We will not share your data with third parties except where required for your treatment or by law. Full details: Patient Privacy Policy.
You must confirm your consent to proceed.
Please enter your name as a signature.
Date

Your completed form will be sent securely to our reception team.

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Thank You

Your registration has been received. We look forward to welcoming you to Pont Steffan Dental.
A member of our team will be in touch shortly to confirm your first appointment.

Please note: to book your first appointment, we require the full New Patient Consultation fee as a deposit.

Questions? Call 01570 422595

Last reviewed: 30 July 2026

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