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Home
Team
Invisalign & iTero
Dental Implants
Cosmetic Bonding
Treatments
General Dentistry
Children Dentistry
Fissure sealants
Hygienist
Mouthguard
Root Canal Treatment
Cosmetic Dentistry
Invisalign
Prosthodontics
Teeth Whitening
Veneers
White Fillings
Facial Aesthetics
Restorative Dentistry
Crowns
Dentures
Prosthodontics
Fees
Private Fees
NHS Fees
Referral & CBCT
Job Vacancies
Contact Us
Confidential Registration Form
Advance Dental Care
Please correct your input in the following fields:
NHS / Private / Dental Insurance?
Title & First & Last Name:
Date of Birth (DD/MM/YYYY):
E-mail address:
Home Address:
Home Post Code:
Mobile:
NHS Exemptions?
Are you taking any medication?
Allergies?
Medical history of Asthma, Bronchitis, Bone/Joint Condition, Epilepsy, HIV, Hepatitis B or C, Heart Conditions, Diabetes, Blood Pressure?
Units of Alcohol per week:
Do you Smoke? if Yes, how many per day?
New Patient Registration
Advance Dental Suite
Patient Type
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I am a Private Paying Patient
I pay NHS Fees
I have NHS Exemptions
Title
First & Last Name:
Date of Birth
Email Address
Phone Number
Occupation
Address
Post Code
GP Name & Address
Interested in:
Teeth Whitening
Dental Implants
Straight Teeth
Facial Aesthetics / Anti-wrinkle injection
Cosmetic Veneers / Hollywood Smile
Are you taking any medication?
Are you pregnant? (If applicable)
Allergies?
Medical history of Asthma, Bronchitis, Bone/Joint Condition, Epilepsy, HIV, Hepatitis B or C, Heart Conditions, Diabetes, Blood Pressure?
Units of Alcohol per week:
Do you Smoke? if Yes, how many per day?
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