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Registration form

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Nameyour full name
Date of birth
Age
Address
Post code
Home tel
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Mobile tel
NHS Number
Occupation
Doctor's Name
Doctor's Address
Postcode
Doctor's tel
How did you hear about this practice?
How long is it since you last visited a dentist?
If other, please state:
Do you need free interpreter service?
If yes, which language?

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Terms and conditions

Appointments and Cancellation Notice
1. We respectfully request that you arrive in good time for your appointment. If you are late we may need to shorten your appointment
time or rearrange it so as not to run late for Patients with appointments following yours.
2. We require 24 hours notice for cancellation of Dental appointments and 48 hours for Hygiene appointments. Where a late
cancellation is made, such as on the morning of the appointment, you become liable for a charge equal to the cost of the appointment.
3. Where an appointment is not met and no notice is given you become liable for a charge equal to the cost of the appointment.
4. The following information will help you to see how long your work is guaranteed for. If asked, your dentist will explain this in greater detail,
prior to any treatment:
a. Fillings will be guaranteed by the dentist for 3 months after treatment.
b. Crowns and Bridge work will be guaranteed by the dentist for re-cement, re-fit and caries developing for up to 6 months. For breakages
requiring the laboratory to remake the work, the laboratory guarantee their work for up to 12 months. Zirconia crowns and bridge work will
be guaranteed by the laboratory for 5 years, Please note that where the laboratory guarantee their work, if it is 6 months after the initial fit
the dentist will need to charge for their time to refit the free laboratory work.
c. Root Canal Treatment and Extensive Periodontal Care Treatment do not carry guarantees. Should you require either of these treatments
your dentist will discuss with you the likelihood of success in your case, and provide you with all the information you need to make an
informed decision.
Fees and Payments
5. If you received care under the NHS please refer to our reception poster, ‘How much will I pay for NHS dental treatment’.
6. Dental Fees: We aim to provide every Patient with a detailed breakdown of their treatment costs as an estimate before booking an
appointment, as it is part of making an informed decision about any treatment. You will be asked at the time of booking an appointment
whether you have been given the necessary information about the cost of the treatment.
7. Should you join our MembershipPlan, the first consultation appointment is not included in the plan cost.
8. If you join our Membership Plan and wish to cancel the plan, we will require 3 months notice. You will be entitled to use any remaining
appointments which are calculated, pro rata, to your annual entitlement and usage on the date of cancellation. If you have contributed
less than the cost of any dental examinations or Hygienist visits already received, we will require either the remaining sum to be paid, or
the appropriate number of monthly payments to be made before cancelling the direct debit. Where a direct debit is cancelled and an
outstanding amount for treatment received has not been paid we will send out an account requesting payment.
Your Information – What you need to know.
9. The Practice requires personal information about you so that we can provide the healthcare you deserve. We treat this information with
the utmost care and store it according to strict guidelines and legislation. Detailed information about this and how you can access your
information, is available in our leaflet,‘How we look after information about you’. This is available from our receptionist or alternatively we
are happy to send you a copy by post or email.
By signing this form you confirm that the information you have given us is true and you accept our Terms and Conditions.