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.