Private Dentist Waiting List Form

Please complete the information below in awareness of the Data Protection declaration statement. Until we contact you, you cannot make a dentist appointment. Whilst waiting for us to complete your private dentist registration, you can visit our private dental hygienist using the direct-access method.

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)

Already registered with our private hygienist?

Message (Private Dentist Waiting List):*

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

I am over 18 years of age and a UK citizen. I hereby agree that my personal data entered in the New Patient Web Contact 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 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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