Call us on 020 8942 8943

Registration form

Nametitle and full name
Date of birth
AddressFull address
Post code
Home tel
Work tel
Mobile tel
NHS Number
Doctor's Name
Doctor's Address
Doctor's tel
How did you hear about this practice?
How long is it since you last visited a dentist?
If other, please state:

Would you like to request a ground floor surgery as our first floor surgeries are only accessible by stairs?

Completed by
If you DO NOT want us to contact you by text or email with appointment reminders or information on treatment please tick this box


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.

2. We require 24 hours notice for cancellation of routine dental appointments  and 48 hours for dental treatment and 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.

Fees and Payments

4. We aim to provide every patient with a detailed breakdown of their treatment costs as an estimate before booking an appointment. If you receive care under the NHS please refer to our reception poster, ‘How much will I pay for NHS dental treatment’.

5. Should you join our MembershipPlan, the first consultation appointment is not included in the plan cost.

6. 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.

7. Some dental treatment comes with a guarantee. Please discuss this further with your dentist prior to treatment.


Your Information – What you need to know.

8. 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.



Color Skin

In light of the recent COVID-19 pandemic, the Chief Dental Officer has advised closure of all dental practices for the foreseeable future.

All routine dental examination and treatment appointments are cancelled until further notice.
Our primary interest is to protect the health and safety of all patients and staff, in line with current guidance.

Our telephone lines will operate between 10am – 5pm Monday to Friday, for emergency phone triage and advice only.
For all none urgent enquires please email

We appreciate your understanding and cooperation, at these unprecedented and difficult times.