Online Registration Aliwal North Please enable JavaScript in your browser to complete this form.Name *FirstLastDate Of Birth (DDMMYYYY) *Address *Address Line 1CityState / Province / RegionPostal CodeEmail *Phone *Best time to contact *9am - 11am11am - 1pm1pm - 3pm3pm - 5pm5pm - 6:30pmAre you intending to register other member of your family with the practice: *YesNoOther Member (Name - DOB - Contact Number) *Appointment type: *UrgentRoutinePlan *NHSDenplan EssentialsDenplan CareWould like more info before deciding Do you have any of the following issues: *Broken teeth DiscolourationBleeding GumsSpacesBadly fitting denturesNervous patientTooth DecayLoose teeth No problems, would like check upOtherOther issues detailsI would like more information on: *Implants Cosmetic Tooth AlignmentTooth whiteningWrinkle & fine line reduction The WandSedationAlpha Stim Smile DesignHow did you hear about our practice: * Recommendation/ Word of mouthDriving pastGoogle SearchSocial MediaLeaflet/flierPlease provide your consent for us to contact you.* *I acceptI do not acceptPlease understand that by submitting this form, you consent to future contact from Waterside Dental Clinic. This includes both marketing and non-marketing communications by phone and or email. We will never sell your personal data under any circumstances & you may opt-out of receiving our communications at any time.CommentSubmit Svyetlahorsk
