Waiting List Form

Start Time

:HourMinutesAM/PM Option
Name*

TitleFirst NameLast Name
Date of birth*

DayMonthYear
Email*
example@example.com
Contact Number*
Gender*

MaleFemalePrefer not to say
Would you like to register as a family?*

YesNo
Number of children under 11
Number of children under 18
Number of adults extra (eg: your spouse)

Your Appointment
What days of the week are best for your appointments?

MondayTuesdayWednesdayThursdayFridaySaturday
Do you worry about your dental visit?

YesNo
Please explain what worries you:

Emergency Contact Info
Name*

First NameLast Name
Emergency Contact Number*
Relationship to Patient*

Consent
Consent for use of clinical data at GDCG Ltd:

Please note that all treatment carried out at GDCG LTD is documented potentially physically, photographically and on video as part of your clinical record such as:
- Sharing data, such as impression moulds, with dental laboratories in order for them to make medical devices such as crowns, bridges, mouthguards and dentures.
- Sharing clinical records with medical and or dental colleagues if you need a referral
- Sharing medical records to a medical colleague if sedation is required
- 3rd parties directly involved with your clinical care
We do not sell data to any third parties and when we share data it will be a limited amount of information that is needed to improve your clinical care.

We are bound by the current General Data Protection Regulation (GDPR) 2018. (Please see GDCG LTD's current Terms and Conditions.)
I consent for data and image to be shared as described above*

YesNo
Please email us on manager@gentledentalcaregroup.co.uk with your concerns or questions and kindly copy in the name of your dentist and when your appointment time is alongside your name to ensure we assist you as quickly as possible. Thank you
Please email us on info@thedentureclinic.co.uk with your concerns or questions and kindly copy in the name of your dentist and when your appointment time is alongside your name to ensure we assist you as quickly as possible. Thank you
I consent for use of clinical images and video As well as being a necessary and indispensable part of your clinical record, these images may be used anonymously for the purposes of teaching, conference presentation, website, articles or promotional material, in the UK and abroad.*

I consent to all images being used anonymouslyI consent to all images being used anonymously apart from those where a substantial or identifiable part of my face is shownI do not consent for my images to be used
Are you registering on behalf of someone? (Parent/Carer)*

YesNo
Name
Relationship to patient
Should be Empty:

Patient Dental & Medical History

Your Appointment

Medical History

Emergency Contact Info

Your Smile

Your Gum Health

Your Teeth & Jaw Health

Dentures & Implants

Consent