Free Dental Treatment Application Form

This is the information we need to register with you with the Dental Hospital. Initial appointments will be for assessment only. Please use the check boxes in the 'Availability' section at the end of this form to indicate the days and times you can attend.
For people applying now, appointments are likely to be in September / October 2014.

All fields marked * are mandatory.

  • Your Details

     
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  • Pick a date.
     
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  • Telephone Numbers

    If you are happy to be contacted by telephone, please complete your best contact number

     
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  • Registered Doctor's Details

     
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  • Availability

     
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  • Data Protection Statement: Your data will be accessed by senior clinical and administrative staff of the School of Dental Sciences and Newcastle Dental Hospital for the sole purpose of registering you with the Dental Hospital and then arranging an appointment for your initial dental check-up. Your data will be removed when this process has been completed. Your data will be managed at all times in accordance with the Data protection Act 1998.
     
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