Stalybridge Dental Care Expression of Interest

Expression of Interest Form

Thank you for your interest in joining Stalybridge Dental Care.

At this time, we are able to accept a limited number of long-term patients, so if you could complete and return the expression of interest form, one of our reception team will contact you when we are able to offer you a New Patient assessment, the cost for this 30-minute appointment is £85.00.

We are a fully private practice and do require all our patients to be on a payment plan, a typical monthly direct debit is £22.35 per month for an adult. The dentist will discuss with you as to which plan is best for you during your initial consultation.

Please be aware that a deposit of £30.00 will be required when booking your initial appointment.

Stalybridge Dental Care

Data protection privacy notice for patients

In providing your dental care and treatment, we will ask for information about you and your health. Occasionally, we may receive information from other providers who have been involved in providing your care. Our privacy notice describes the type of personal information we hold, why we hold it and what we do with it.

View our full privacy policy

About You

Name

Address

Postcode

Date of birth

Mobile Number

Please answer all the following questions

How did you hear about the practice?

When was your last dental visit and what was it for?

History of visits prior to this

Are you looking to become a long-term regular patient or just 2^nd opinion/short term treatment?

We require all patients to be on a dental plan and we will give you the information regarding our Denplan scheme, and answer any questions you may have when we call you.
We will complete your plan sign up at your first appointment, so please bring Direct Debit information with you.

Do you have a dental scheme already? If yes, which scheme?

Any health issues relating to going upstairs?

Occupation/ease of attending practice in normal hours?

Are you a nervous patient? What worries you?

Are you happy with your smile? If not, what would you change?

Do your gums bleed when you brush?

Are your teeth sensitive to hot or cold?

Do you have any immediate problems?