New Patients | Whitefern Dental Health

NHS Enquiry Form

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PATIENT INFORMATION

First Name

Last Name

Date of Birth

Gender

Paying Type

Where did you hear about us

Mobile Number

Home Phone Number

Address

Town

Postcode

TREATMENT INFORMATION

Cosmetic Treatments

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

DECLARATION

Contact Confirmation

I confirm that the contact details above are correct *

Leave Message

I authorise Whitefern Dental Health to leave a message for me on the following telephone number

Phone Number

Additional Contact

I authorise Whitefern Dental Health to communicate with my Husband/Wife/Partner/Parent/Carer.

Name

Relationship

Marketing

I permit Whitefern Dental Health to use any of my personal data for use for marketing, promotional, educational, training or any other purpose than my care & treatment. Please state your preferred method:

Preferred Communication Method

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 Colchester.

Private Patient Registration Form

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PATIENT INFORMATION

First Name

Last Name

Date of Birth

Gender

Where did you hear about us

Mobile Number

Home Phone Number

Address

Town

Postcode

TREATMENT INFORMATION

Cosmetic Treatments

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

DECLARATION

Confirm Details

I confirm that the contact details above are correct

Leave Message

I authorise Whitefern Dental Health to leave a message for me on the following telephone number

Phone Number

Additional Contact

I authorise Whitefern Dental Health to communicate with my Husband/Wife/Partner/Parent/Carer.

Name

Relationship

Marketing

I permit Whitefern Dental Health to use any of my personal data for use for marketing, promotional, educational, training or any other purpose than my care & treatment. Please state your preferred method:

Preferred Communication Method

General Dentistry

Orthodontics

Cosmetic Dentistry

Implants

Pain Free Dentistry

Dental Emergency

Laser Dentistry

Digital Dentistry

Integrative Therapies

New Patient Registration

NHS Enquiry Form

PATIENT INFORMATION

TREATMENT INFORMATION

DECLARATION

Private Patient Registration Form

PATIENT INFORMATION

TREATMENT INFORMATION

DECLARATION

Opening Hours

Contact

Services

Are you a Dentist?