Please fill out all fields. Fields marked with * are required.
To the best of your knowledge do you have or have you suffered from the following? If possible please provide approximate date of diagnosis.
There are many medications that may impact upon your oral health or the treatment we plan for you. Please indicate medications that you are currently taking or have taken most recently.
I accept responsibility for my account and understand that the fee is payable on the day. Should I be unable to pay on the day I understand the payment is due within 30 days; if my account exceeds 30 days I understand an account keeping fee may be incurred. If my account remains overdue and is referred to a debt collection agency or solicitors, I may be held liable for the costs of such collection plus interest. I accept full responsibility for health fund claims and rejections. Any fees incurred by the practice for cheques not accepted by the bank may be passed to me.
How Can We Help?