We want to make sure you can read and understand the information we provide. If you find it hard to read our letters and forms, or if you need someone to support you at appointments, please let us know.
If you would like this form in an alternative format, for example large print or easy read
please ask our reception team.
Under the new General Data Protection Regulations, we must ensure that all information that we hold about you is accurate and up-to-date, therefore we need to take some details from you for our records to ensure that we provide you with the best level of treatment. We will use the contact details you provide us with to contact you.ontact you.
We store our records on our dental database which is security and password protected. They are stored in accordance with the General Data Protection Regulations under the Data Protection Act 2018. If you would like further information about how your dental records are stored please ask our reception team.
Please initial below if you are happy for us to store your personal information:
We may need to share your information with other healthcare professionals who need to be involved in your dental care i.e.: Dental Specialist or Laboratory. Your personal information is not shared or forwarded on to any other organisation or company.
Please initial below if you are happy for us to share your personal information as part of your ongoing dental care:
Your dental records comprise of computerised/written notes, radiographs (x-rays), digital photographs and stone models of your teeth. We request consent from you for us to use these for demonstration, training and marketing purposes. Your identity will always remain anonymous.
You can withdraw all or part of your consent for this at any time, please let us know in writing.
We may, occasionally, send out emails informing you of any special offers or events that are taking place at the practice. Please initial below if you would like to continue receiving these emails:
Please state the names and relationship of anyone authorised by you to contact us on your behalf concerning any of the following: Appointments, change of details e.g. address, aspects of treatment, payments for treatment, other
Have you ever had in the past:
In the past 5 years have you been hospitalised for:-
I confirm that the information I have provided on this form is accurate and true. I understand that falsifying or withholding information may prevent me from receiving accurate treatment for my needs.