Join Our NHS Waitlist

Please complete all sections of the form accurately.

We need all the information requested in order to add you to our NHS waiting list. We unfortunately cannot estimate waiting times. Once we have availability, we’ll get in touch with you directly. If you need an emergency appointment, a hygienist treatment, or would like to be seen as a private (non-NHS) patient, please use our online booking platform to schedule these appointments. You are guaranteed to be seen sooner if you book online.

Title

Gender

Date of birth

Day

Month

year

First name

Last name

Address

City

Postcode

Email address

Mobile number

Details

NHS Number

Are you receiving any benefits that exempt you from paying NHS dental charges?
YesNo

If yes, please specify which benefits you receive.
Not all benefits will exclude you from paying NHS charges. It is the patients responsibility to know whether they are exempt or not, if you are unsure you should check before booking. Please bring proof of your benefit with you when you attend for appointments.

Previous practice details

Previous practice details

Last dental visit

Current dental issue

Do your gums bleed when you brush?
NoYes

How did you hear about us?

We’ll contact you by phone and email when we have availability for your initial assessment.

Please double-check that your contact details are correct, and keep an eye on your junk or spam folder in case our message ends up there.

Attending your initial assessment is essential to complete your registration. If you miss this appointment, we won’t be able to offer you another slot, and you’ll need to rejoin the waiting list to be considered again.