NHS Leeds website is no longer live - this content is for historical use only

Date:
19 May 2013
Page URL:
http://www.leeds.nhs.uk/Your-local-services/Online-dental-access-form.htm?textonly=1&shortcutid=134938

Please complete the form below making sure to fill in any required fields. Once you are happy that all the information is correct please click send. We will contact you as soon as possible after you have submitted the form.

Name (required)

Date of birth (required)

Address (UK Style)

Address line 1

Address line 2

Town

Region

Country

Postcode

Telephone

Mobile number

Evening contact number

Primary language (required)

Gender

Male Female

Ethnicity

Disabled access required (required)

Yes No

Please provide the Name and Date of Birth of any other family member that you wish to include in this registration form.

Additional family members

Previous dentist

Dentist address

Address line 1

Address line 2

Town

Region

Country

Postcode

Date last seen dentist

Please fill in the following information if you are a social worker/carer registering on behalf of someone else.

Worker/carer

Yes No

Name

Address

Address line 1

Address line 2

Town

Region

Country

Postcode

Where did you hear about the Dental Advice Line?

Any other comments or information

This is a printable version of http://www.leeds.nhs.uk/Your-local-services/Online-dental-access-form.htm?textonly=1&shortcutid=134938