New Patients

The Registration Procedure

1

Complete the form below

2

Book a new patient appointment

3

Discuss your dental needs

4

Smile with confidence

New Patient Registration Form

Personal Details

Title

First Name

Surname

DOB

CONTACT DETAILS

Address

Address2

City

Postcode

Phone Number

Dental Enquiry

Select Topic

Description

If you have any documents you would like to send us please attach below.
Documents to send:
1. Medications (Prescription)
2. Radiographs (X-Rays)
3. Previous Treatment Plan
4. Any relevant documents

File Upload

Consent

I consent to my personal data being collected and stored as per the Privacy Policy.

Consent2

I agree to being registered as a private patient at Ilford Dental Care

Your Personal Details

Title *

Name *

First

Last

Date of Birth *

Your Contact Details

Your Phone Number *

Email *

Confirm Email

Address Line 1 *

Address Line 2

PostCode *

Register Family Members

Would you like to register a family member?

Dental Details

Dental Needs *

Dental Issues

Would you like to upload any photographs, documents relevent to your dental issue?

Marketing Source *

Checkboxes *

I consent to my personal data being collected and stored as per the Privacy Policy.
I confirm that I will be registered as a PRIVATE PATIENT.

Captcha *

Website