New patients

Online registration form

If you would like to be seen at Lion House Dental Practice please register your interest below and a member of our reception team will be in touch to discuss availability.

    Your details

    Your first name (required)
    Your surname (required)
    Your date of birth (required)
    Your telephone (required)
    Your email (required)

    Patient one

    Patient name
    DOB

    Patient two

    Patient name
    DOB

    Patient three

    Patient name
    DOB

    Patient four

    Patient name
    DOB

    Patient five

    Patient name
    DOB

    I consent to my personal data being collected and stored as per the Privacy Policy.

    I consent to my personal data being collected and stored for the purpose of marketing communications.

    Although we take every precaution to ensure patient confidentiality we cannot guarantee that the information you provide on this form can be transmitted securely via the Internet. If you are concerned about this please telephone us.