PLEASE FILL THE NHS FORM
Full Name
*
Date of birth
*
Email
*
Phone
*
Address
Street Address
*
State
Postal code
*
Are you exempt from payments?
*
Yes - I am exempt
No - I will pay for dental treatment
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Please select your exemption category:
*
Under 18
Aged 18 and in full-time education
Pregnant or had a baby in the last 12 months
Income Support
Universal Credit
Jobseeker’s Allowance
Pension Credit
HC2 Certificate
Other
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Other Exemption (please specify):
*
Do you currently have any urgent dental concerns (e.g. pain, bleeding, swelling)?
*
Yes
No
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Please select your urgent dental concern:
*
Pain in gums
Swelling of gums
Bleeding
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When did you last see your dentist?
*
None...
0-1 year
1-3 years
3+ years
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Do you wear Dentures if any type?
*
Yes
No
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Please select the type of dentures you wear:
*
Full Dentures
Part Dentures
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Are you willing to attend the practice at short notice – within 24/48 hours if an appointment becomes available?
*
Yes
No
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Do you believe you need any of the following mandatory treatments?
*
Fillings
Extractions (tooth removal)
Dentures
None of the above
Are you interested in any of the following?
*
Teeth whitening
Teeth straightening
Cosmetic bonding & Smile Makeover
Implants
Hygiene visit
None of the above
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