Private Patient Registration

PATIENT INFORMATION

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Name *

Date of Birth *

Gender *

Email *

Paying Type *

Where did you hear about us *

Mobile Number *

Home Phone Number *

Address *

Town *

Postcode *

TREATMENT INFORMATION

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Cosmetic Treatments *

Description of any issues you may have with you teeth that concern you. *

I confirm that the contact details above are correct

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

Phone

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

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Name

Relationship

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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:
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.

General Dentistry

Cosmetic Dentistry

Family Friendly

Laser Dentistry

Dental Hygiene

Specialist Dentistry

Private Patient Registration