NHS Child Registration Form

Your child's first Dental Checkup appointment will be with a Wedgwood House treating clinician, typically one of our two dental therapists, Jenna or Vineela. One form per child please.

If you were hoping to register for adult NHS services or private services, sorry this is not the form. If your child requires an emergency appointment and unregistered (or yet to have their first dental checkup) please call the reception team after 9:15am or NHS 111.

Is the child in pain (i.e. requiring an EMERGENCY appointment not dental checkup)?

Application to register a child with a WHDP treating clinician for a dental checkup. Full Name:*

This field is mandatory

Date of Birth (DD/MM/YYYY)*

This field is mandatory

Address:*

This field is mandatory

CONTACT Email address:*

This field is mandatory

CONTACT Mobile:*

This field is mandatory

Biological sex (as required by the NHS) Male or Female:*

This field is mandatory

Ethnicity (as required by the NHS England), if don't know or unable to provide write "Not Stated": *

This field is mandatory

Name, contact details and relationship (e.g. mother) to child of 1st parent or guardian:*

This field is mandatory

Name, contact details and relationship to child of 2nd parent or guardian:

Emergency contact (unless stated otherwise, this will be the 1st parent or guardian):*

This field is mandatory

Is there additional information we need to be aware of such as an allergy, needing a tooth extracted or filled? Or if there are legal restrictions on who can or cannot consent for the child?

Unless this is the first, then was your child's last dental appointment?

Does your child have a restriction that would require only ground floor access?

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

I am over 18 years of age, a UK citizen, have legal authority to register the above mentioned child, and am aware of the WHDP Privacy Notice. I hereby agree that the child's personal data entered in the Registration Form will be stored electronically by Wedgwood House Dental Practice and will be processed and used for the purpose of establishing contact (the 'CONTACT' email or SMS text number) and, if dentist/therapist availability and diary space permitting, creating a dental patient 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. I understand that future WHDP electronic correspondance will be with one email address or one SMS text number, which is defined by the patient's CONTACT email/mobile.*

* Indicates required fields

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

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