1Consent Form
2Medical History Details
  • Patient's Details

  • Payment

    Please ensure you complete the medical history part of the form for each patient.

    Please note, we require payment before we are able to arrange an appointment. Please check our latest prices here...

    You can make payment by card over the phone, by cheque payable to Leeds Dental Team Ltd, or you can make a bank transfer to:
    Leeds Dental Ltd
    Sort Code: 53-61-07
    Account Number: 70394288

    Please remember to quote the name of the patient the payment is related to as a pay reference. If further treatment is required, you will be given a quote, and payment will be required at the next visit.

  • Consent

  • I, named above, give full consent for Mr G Temple to examine and provide dental treatment
  • MM slash DD slash YYYY
  • Please click Next below to continue to the Medical History Form

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