By signing and submitting, I confirm that the information I have given is true, and that I am fit and healthy to attend Wicham Dental Practice. If you answer "yes" to any of the questions, we respectfully request that you reschedule you appointment.
All information given will be treated confidentially. Wickham Dental Practice will will keep the information collected safely. Any personal information will not be disclosed unless as required by law, or with your express consent.