treatments about blog contact smiles dental health plan go to dentalsurgerygroup.co.uk

Register as a Private Patient at Harlow Dental Surgery.

Please fill out the form below to register as a private patient and we'll get back to you as soon as possible.

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a dental surgery group practice since 2014

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a dental surgery group practice since 2014

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a dental surgery group practice since 2014

•

a dental surgery group practice since 2014

•

a dental surgery group practice since 2014

•

a dental surgery group practice since 2014

•

a dental surgery group practice since 2014

•

a dental surgery group practice since 2014

•

a dental surgery group practice since 2014

•

a dental surgery group practice since 2014

Private Patient Registration Form

Please fill in one enquire form per member of family.

Patient Details

Are You An Existing Dental Surgery Group Patient?^*

If 'Yes', Which Dental Surgery Group Practice Are You Currently Registered With?

What Can We Help You With?^*

Title^*

First Name^*

Last Name^*

Date of Birth^*

Address^*

Postcode^*

Occupation^*

Phone Number^*

Email Address^*

Your Experience with the Dentist

How Do You Usually Feel About Visiting the Dentist?

Are There Any Treatments You Feel Especially Anxious About?^*

How Did You Hear About Us?

Please Tell Us How You Heard About Us^*

Referral Source

Your Dental Needs

How Urgent is Your Dental Problem?^*

More Details^*

Why Do You Need to See the Dentist? Select All That Apply^*

Important Information

I consent to giving my details for the purpose of being added to the Private Patients List and being contacted in response to this form*.

I understand that there will be a £100 consultation fee. The dentist will explain any further treatment costs in writing before treatment begins.The above does not apply if you are joining the Smiles Dental Health Plan for routine care. Learn more about Smiles Dental Health Plan here.

I would like to hear about special offers and updates from Dental Surgery Group.

Thank you! We have received your enquiry. A member of our team will be in touch with you as soon as possible.

Something went wrong when submitting your enquiry. Please try again or email us at info@ashwelldental.com

Practice Address

Harlow Dental Surgery
Chadwick House
Hamstel Road
Harlow
CM20 1EP

We provide NHS and private dental services to the population of West Essex.

Call The Practice: 01279 425 640 / 01462 743117
Email The Practice: info@harlowdental.com

Opening Hours

Monday: 8.30 - 12.30 / 13.30 - 17.00
Tuesday: 8.30 - 12.30 / 13.30 - 17.00
Wednesday: 8.30 - 12.30 / 13.30 - 17.00
Thursday: 8.30 - 12.30 / 13.30 - 17.00
Friday: 8.30 - 12.30 / 13.30 - 16.30
Saturday / Sunday / Bank Holidays: Closed

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