Medical History Form

I give permission to be contacted on the telephone number
Please include your postcode
(requirement under 120kgs)

Female patients

Exemption from Dental charges

COVID-19 ASSESSMENT - Do you have any of the following symptoms of Covid 19:

NHS Patients Under NHS regulations, we are unable to charge NHS patients who fail to attend for their initial appointments or who cancel at short notice (less than 24 hours notice is insufficient notice). A patient who fails to attend their new patient appointments or cancels at short notice, may not be offered any further appointments at this practice, but you may seek another NHS practice elsewhere. Please sign below to acknowledge this statement.


I hereby apply to become a patient of Lighthouse Dental Practice. I undertake to settle all fees when due. I understand that interest may be paid on overdue accounts and that seriously overdue accounts may incur extra fees.