English

Patient Registration

NHS Patient
Record Form

Please complete this form to register as an NHS patient. All information is kept secure and confidential.

NHS Dental Practice Record — Patient Declaration

One form must be completed for each course of treatment. Provide accurate details and sign the declaration. Fields marked * are required.

Patient information

Provider name

Provider address/location

NHS number (10 digits)

Surname *

Forename *

Date of birth *

ETD claim reference number(Staff only)

Evidence of exemption seen(Staff only)

YesNo

Evidence of remission seen(Staff only)

YesNo

Date of acceptance(Staff only)

Phone

Consent to treatment and data useI confirm the information is correct and consent to NHS treatment.

If signing for patient — Your name

Relationship to patient

Ethnicity (optional)

Select ethnic group

Claim for free or reduced-cost NHS dental services

Under 1818+ and in full-time educationPregnantHad a baby in the last 12 months

Are you currently in prison or a young offenders institution?

NoYes

Benefits/certificates that entitle to free NHS dental services (select all that apply)

Income Support

Income-based Jobseeker's Allowance

Pension Credit Guarantee Credit

Income-related Employment and Support Allowance

Universal Credit (criteria apply)

NHS Tax Credit Exemption Certificate/Card

HC2 certificate

HC3 certificate (limited help)

NHSBSA Maternity Exemption Certificate

War Pension Exemption

Declaration

By signing, you confirm the information is correct, understand checks may be made about this claim, and acknowledge charges may apply if not entitled.

Signature *

Sign here

Please sign in the box above

Signature date

Date is automatically set to today

Need Help?

If you have any questions about this form or need assistance, please don't hesitate to contact us.

Call: 01482 656656|reception@willerbydentalcare.co.uk

24/7 Support

Get online access to
ask our chatbot

Have a dental concern? Get 24/7 online access to our trained chatbot and get answers to common questions, anytime, anywhere.

Hi, I have a question about teeth whitening...

Hi! I'd be happy to help. What would you like to know?

Dental Assistant

Available 24/7 for your questions

Blog

Stay updated with dental
wellness tips

Opening Hours

We're here to help with all your dental needs

Monday08:30 - 17:30

Tuesday08:30 - 17:30

Wednesday08:15 - 17:30

Thursday08:30 - 17:30

Friday10:00 - 16:00

SaturdayClosed

SundayClosed

Book an Appointment

Experienced and internationally certified dental practitioners providing exceptional care since 2004.

Quick Links

Home
About Us
Services
Our Team
Contact

Information

FAQ
Price List
Finance
Cancellation Policy
NHS Patient Form
Nervous Patients

Contact Us

81 Kingston Road, HU10 6AH Willerby 01482 656656 reception@willerbydentalcare.co.uk

NHS PatientRecord Form