Patient Registration

Edgerton Dental Clinic Patient Registration Information

NHS WAITING LIST

You will be added to our waiting list and we will be in touch once we have NHS patient capacity.
There is no need to re-register or contact us once you have completed the form, as you will remain on our waiting list until a place becomes available.
If you find an NHS dentist in the meantime, there is no need to let us know until we contact you.

We are able to accept private adult patients at our practice – please call our Private Patient Support Line on 01484 530343 to register. Alternatively please contact the practice if you would like to know more about our dental services or affordable dental plans.

Please complete the form below to join our waiting list.

Please fully complete this registration form.

All items marked with an (*) MUST be completed.

If you are registering with the NHS you MUST provide your NHS number otherwise we will be unable to add you to our list.

Please note that this form does not guarantee access to our services and you may receive a request to complete this form when the practice is preparing to accept new patients.

This application is for:* (required)

Please select who application is for:* (required):

If you are completing the form for a person Under 18yrs of age please give their full name below

If you are completing this form on behalf of someone else please give your relationship to that person (parent, carer etc)

Contact Details

Your Name*

Email*

Your Telephone number *

Patient Date of birth

Patient Address

Patient Postcode

Patient NHS Number

Patient Occupation

Patient Sex:

Payment Exemptions

Are you Exempt from payments?* (required) Please select :

If you are exempt from fees please give the reason why you are exempt below

Patient Dental Health Questionnaire When did you last see a dentist for regular check-ups?* (required) Please select the most accurate Do you have, or are you aware of any cavities (holes) in your teeth?* (required) Are you currently in any pain with your teeth or gums?* (required)

Dental Chair Safety

At EDC your safety is of paramount importance. Our dental chairs have a weight safety limit of 20 stone. Incorrect use could lead to serious injury and as such if you think this may be an issue then please select YES below and ensure your treating dentist is aware of this issue. Alternatively select NO. *(required) Please select :

Other Comments How did you hear about our practice?

Comments

How you prefer to be contacted:

required fields marked *
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Term and conditions

There are some terms and conditions upon registering. This includes adhering to the practice policies.

PLEASE NOTE – If you have already been removed from our active patients for a reason, then you will not be placed back onto our lists.

If a new NHS patient misses their first appointment they will automatically lose access to NHS services at the practice.

The above will apply where less than 24 Hours notice is given.

EDC will have complete discretion with regards to exceptional circumstances.

Monday	9.00am - 5.15pm
Tuesday	9.00am - 5.15pm
Wednesday	9.00am - 5.15pm
Thursday	9.00am - 5.15pm
Friday	9.00am - 5.15pm
Saturday By arrangement

Edgerton Dental Clinic Patient Registration Information

NHS WAITING LIST

Please complete the form below to join our waiting list.

Term and conditions

Quality care for a lifetime of happy smiles