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First Name *

Last Name *

Phone *

Email *

Is this your first visit? *

Yes

Do you have HMO coverage? *

Yes

White Teeth Dental collects your name, phone number, email and the answers on this form to reply to your inquiry, book your free consultation, and send appointment confirmations and reminders. We handle your information under the Data Privacy Act of 2012 (RA 10173). It is stored in our secure booking system, which is hosted outside the Philippines, and only clinic staff who need it to assist you can see it. If you don’t become a patient, we delete your inquiry details after [12 months]. Please don’t include medical details here; your dentist will review your health history with you at the clinic.

I have read the Privacy Notice and agree that White Teeth Dental may use my details to respond to my inquiry and manage my appointment, including confirmations and reminders by SMS, email or Messenger.

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