Personal information
Title:
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-- Select Title --
Mr
Mrs
Miss
Ms
Dr.
Full Name:
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Address:
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Town:
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County:
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-- Select County --
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cornwall
Cumberland
Derbyshire
Devon
Dorset
Durham
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Huntingdonshire
Kent
Lancashire
Leicestershire
Lincolnshire
Middlesex
Norfolk
Northamptonshire
Northumberland
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
Staffordshire
Suffolk
Surrey
Sussex
Warwickshire
Westmorland
Wiltshire
Worcestershire
Yorkshire
OTHER
Post Code:
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Tel(H):
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Tel(W):
Mobile:
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Email:
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Date Of Birth:
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Select Gender:
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Male
Female
Marital Status:
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-- Select Status --
Civil Partner
Divorced
Married
Separated
Single
Widowed
Place Of Birth:
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Nationality:
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Ethnic Group:
-- Select Ethnic --
Asian or Asian British Bangladeshi
Asian or Asian British Indian
Asian or Asian British Pakistani
Black or Black British African
Black or Black British Caribbean
Chinese
Other Asian Background
Other Black Background
Other Mixed Background
Other White Background
White & Asian
White & Black African
White & Black Caribbean
White British
White Irish
Any other Ethnic Group
Patient Declined
Are you currently in employment?
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-- Select Employment --
Yes, Full-time
Yes, Part-time
No, I am unemployed
No, I am looking for work
Occupation:
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-- Select Status --
Accountant
Agricultural EngineerAgricultural Engineer
AI and Machine Learning EngineerAI and Machine Learning Engineer
Architect
Banker
Barrister
Bartender
Builder
Building Surveyour
Business Consultants
Call Centre Telephonist
Caregiver
Carpenter
Chef
Cybersecurity Specialists
Data Analyst
Delivery Driver
Dentist
Electrician
Farm Worker
Financial Analyst
Fishermen
Graphic Designer
HGV Driver
Hotel Manager
HR Manager
IT Support Technician
Joiner
Journalist
Judge
Labourer
Legal Secretary
Marketing Specialist
Medical Doctor
Musician & Performer
Nurse
Occupational Therapist
OTHER
Paralegal
Paramedic
Pharmasist
Photographer
Physiotherapist
Plumber
Quantity Surveyor
Radiographer
Receptionist
Retail Assistant
Roofers
Salesmen
School Teacher
Social Media Manager
Software Developer
Solicitor
Special Educational Needs Teachers
Support Worker
Taxi Driver
Teaching Assisstants
Train and Tram Operator
University Lecturer
Veterinarian
Video Editor
Waiter / Waitresses
Warehouse Operative
Web Developers
NHS No.
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Nat Ins No.
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Do you have any family members from the same household who are already registered here ?
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yes
no
I dont know
Who was your last dentist:
When did you last see your Dentist?
-- Please Select --
Less than 6 months ago
6 - 9 months ago
9 - 12 months ago
Over a year ago
Never seen a dentist
Has any dental practice refused to accept you as a patient?
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Yes
No
-- Please Select --
Bad Debt
Gone Private
Missed Appointments
Not accepting NHS patients
Other
Where did you hear about us?
-- Please Select --
Google
Instagram
Linkedin
Mail
Other
Passing by the practice
Recommendation
Youtube
Please select one option only from the list below to indicate the scheme you would like to register under:
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Denplan
Emergency Scheme
- Our Emergency Scheme provides advanced treatments with a choice of both advanced and standard materials. Enjoy flexible appointment times between 9 AM and 5 PM, with same-day appointments available (subject to availability) and no waiting time for bookings, ensuring prompt and effective care when you need it most. Suitable for patients who are not registered with us.
Private Scheme
- Our Private Scheme offers advanced treatments, access to state-of-the-art materials, and flexible appointment times between 9 AM and 5 PM. Enjoy competitive pricing with no waiting time for bookings, ensuring prompt and high-quality dental care tailored to your needs.
Independent Scheme
- Our Independent Scheme provides standard treatments with a wider choice of standard materials at rates lower than private care. Enjoy flexible appointment times between 10 AM and 4 PM, with no waiting time for bookings, ensuring convenient and affordable dental care.
NHS Scheme
- Our NHS Scheme provides standard treatments using standard materials at fixed prices set by the NHS. Appointment times are limited between 11 AM – 3 PM for adults and 9 AM – 5 PM for school children under the age of 18 years. Due to high demand, shortage of NHS dentists, and limited capacity, our waiting times is significantly long.
NHS Patients only - If you are exempt from NHS dental charges, please tell us the reason by ticking the box below
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-- Please Select --
I am under 18 years of age
I am 18 years of age and in full time education
I am pregnant
I had a baby in the last 12 months
I am currently in prison
I am currently in a young offenders institution
I receive Income Support
I receive income-based jobseeker's allowance
I receive income-related Employment & Support Allowance
I receive Pension Credit Guarantee Credit
I receive Universal Credit
I have a HC2 Certificate
I have a HC3 Certificate
I have NHS Tax Credit Exemption Certificate
Proof of Exemption:
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Yes
No
Certification Number:
Expiry Date:
What is the reason for coming to this practice?
-- Please Select --
Had an emergency
Moved into this area
Never been to a dentistNever been to a dentist
Other
Recommended by family or friends
Taken off the NHS by my previous dentist
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I acknowledge and agree to make payment for my course of treatment at each visit, covering the services provided on that day. Failure to complete payment will result in the removal of my name from the Dentist’s Register. To reinstate my registration, I understand that I must settle any outstanding balance in full, along with a reinstatement fee of £50. Additionally, I confirm that I have reviewed all notices displayed on the practice's Notice Board and am fully aware of the cancellation policy of the practice. By signing below, I agree to comply with the practice's policies and accept the stated terms and conditions.
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