Private Dentist/Therapist Registration Form

Whilst waiting for reception to call you back to offer you an appointment, you can instantly book a

private dental hygienist appointment using the direct-access method
dental check-up with our dental therapist.

Our dental therapist has private appointments on Tuesday mornings and our private hygienist works Wednesday to Friday. (Our private dentists typically are not shown on the online booking system.)

If you were hoping to register for NHS services, sorry this is not the form.
If you have severe dental pain, please ring the reception team on 01449 771 700 and ask for a private emergency appointment.

Application to register with the Private Dentist-Therapist. Full Name:*

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Date of Birth (DD/MM/YYYY)*

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Address:*

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E-mail address:*

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Mobile:*

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Alternative (e.g. landline)

Would you like to register for both the private hygienist AND the private therapist/dentist?

When was your last dentist/therapist/hygienist appointment(s)?*

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Do you have a restriction that would require only ground floor access?

Is there additional information we need to be aware of such as you have an allergy, you need a tooth extracted or filling, are you interested in dental implants or tooth whitening?

Name(s) of additional family members with date of birth (if applicable):

I understand the GDC restrictions on dental therapist (see Services/Dental Appointments for more info).*

This field is mandatory

I am over 18 years of age and a UK citizen and am aware of the WHDP Privacy Notice. I hereby agree that my personal data entered in the Private Dentist/Therapist Registration Form will be stored electronically by Wedgwood House Dental Practice and will be processed and used for the purpose of establishing contact and, if dentist/therapist/hygienist availability and diary space permitting, creating a dental patient contact medical record. I am aware that I can revoke my consent at any time, though deletion of dental records is prevented by the UK Data Protection Act 2018. The dental practice reserves the right to exclude requests from ex. (inactive) patients. *

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* Indicates required fields

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Thank You. We will get back to you as soon as possible.

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