New Patient

new patient
First Name *
:

Surname *
:

D.O.B *
:

Gender *
:

Mobile No *
:

Home Phone No *
:

Email *
:

Address *
:

Town *
:

Postcode *
:

Paying Type *
:

Cosmetic Treatments*
:

Special Request
:

Where did you hear about us *
:

I confirm that the contact details above are correct & that I prefer to be contacted by Bluebell Dental Practice by the following method's

Following method's of communication *

Home phone
Mobile
Text/SMS message
Email
Letter by post

I authorise Bluebell Dental Practice to leave a message for me on the following telephone number

I authorise Bluebell Dental Practice to communicate with my Husband/Wife/Partner/Parent/Carer.

Name
:

Relationship
:

Permitted use of personal data (please select either clause A or B) *:

A) In the event that any person working at Bluebell Dental Practice wishes to use any of my personal data for use for marketing, promotional, educational, training or any other purpose than my care & treatment, I permit the practice management to make an information request to me using the following method: (specify how to be contacted here:)

B) I DO NOT permit the practice management to request using my personal data for any purpose other than my care & treatment.

Note: ‘Manufacturer guidelines state that the maximum weight that our dental chairs can hold is 120kg. Please speak to reception if you have any queries regarding this and we may be able to refer you to our local community care centre in Hainault.’

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