Online Waiting list application

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First name

Last name

Date of Birth

Phone

Occupation?

Street Address

Street Address Line 2

City

Post code

NHS Number?

Friends or Family registered at practice?

Where and When did you last visit a dentist?

Please list below all other family, that you want us to consider for registration. These people must reside at the same address as the person above

Full Name

Date of Birth

Relation to you

Contact Number

Full Name

Date of Birth

Relation to you

Contact Number

Full Name

Date of Birth

Relation to you

Contact Number

Full Name

Date of Birth

Relation to you

Contact Number

Consent for waiting list

I understand that as a regularpatient at Loddon Bridge Dentall, I need to attend regularly for my examinations in order to retain my registration. If I do not attend within a two year period, I may lose registration

I understand that I will be put on a waiting list, this DOES NOT guarantee registration

I understand that NHS dental treatment is not free, unless I am on a relevant exemption, I will need to pay the NHS charges for treatment

I understand that I will be required to pay a deposit for my first registration appointment

I understand that failure to attend my first registration appointment may result in losing my opportunity to be a registered patient

I undersatnd that I cannot book ANY appointments until after I have attended my registration appointment

Thank you for applying for our waiting list! If your application is successful, someone will be in touch when we have space to take you on.

Online Waiting list application

Page Last updated 07.06.24 (JD)