Recall

PATIENT DECLARATION

Practice record form
Please select your practice*
Name of patient*

First NameLast Name
Date of birth*

DayMonthYear
Date
I consent to the dental provider named above, or their representative, to examine me under the NHS and to give me any necessary care and treatment that I am willing to undergo within NHS arrangements. I agree to pay the statutory charges for the NHS dental service I receive, unless I have completed a valid claim for free or reduced cost NHS dental services below, and that I may have to pay the full amount prior to treatment. I agree, if necessary, to be examined and/or to have my dental records examined by the NHS Business Services Authority (NHSBSA) or other authorised bodies. I declare that the information I give on this form is correct and complete. I understand that if it is not, appropriate action may be taken against me.
Signature*

Clear
Date

DayMonthYear
Date
Are you signing on behalf of the patient?*

YesNo
Name*

First NameLast Name
Relationship to patient*

To enable the NHS to prevent and detect fraud and mistakes, pay dentists and to secure the effective and efficient delivery of NHS and related services, relevant information on your NHS treatment may be shared with, and by the NHSBSA to NHS England, Department for Work and Pensions, HM Revenue & Customs, NHS Digital, NHS Counter Fraud Authority, NHS Service Commissioners and bodies performing functions on their behalf. Your personal data will be deleted within 10 years of receipt into our systems. Further details are available at www.nhsbsa.nhs.uk/yourinformation
Email*
Mobile Number*

PATIENT DECLARATION