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HALF PRICE PRIVATE EXAMINATIONS! BOOK NOW!
0151 228 3643
HALF PRICE PRIVATE EXAMINATIONS! BOOK NOW!
About
Our Team
News
Our Vision
Our Patients
Our Technology
Our Charity Partner
General Dentistry
Emergency Dentist
Dentures
Dental Bridges
Root Canal Treatment
Dental Fillings Liverpool
Healthy Gums
Sedation
Facial Aesthetics Liverpool
Cosmetic Dentistry
Teeth Whitening
Composite Bonding
Dental Implants
Orthodontics
Braces
Invisalign
Fees & Finance
Our Membership Plan
Referrals
Refer a Friend Card
Refer a Patient
Contact
Book Now
Menu Toggle
About
Menu Toggle
Our Team
News
Our Vision
Our Patients
Our Technology
Our Charity Partner
General Dentistry
Menu Toggle
Emergency Dentist
Dentures
Dental Bridges
Root Canal Treatment
Dental Fillings Liverpool
Healthy Gums
Sedation
Facial Aesthetics Liverpool
Cosmetic Dentistry
Menu Toggle
Teeth Whitening
Composite Bonding
Dental Implants
Orthodontics
Menu Toggle
Braces
Invisalign
Fees & Finance
Our Membership Plan
Referrals
Menu Toggle
Refer a Friend Card
Refer a Patient
Contact
Book Now
Cosmetic Consultation
Step
1
of
4
– Smile Assessment
25%
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Referrer Name
First
Last
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Referrer Email
Online Smile Assessment
We would love all our patients to have a smile they can be proud of. Please answer the following questions- and add any further comments that might help us to understand how we can best help you.
How happy overall are you with your smile?
Please indicate any areas you are unhappy with
Shape of teeth (Interested in Composite Bonding / Composite Veneers)
Colour of teeth
Alignment of teeth
Missing teeth or spaces
Freshness of my breath
Sensitive teeth
Bleeding gums
Previous dental work
Lines or wrinkles on face
In detail, please tell us the reason for your enquiry today. Any other comments?
Your Photographs
Front Closed View
Accepted file types: jpg, jpeg, png, bmp, Max. file size: 15 MB.
Left Side Closed View
Accepted file types: jpg, jpeg, png, bmp, Max. file size: 15 MB.
Right Side Closed View
Accepted file types: jpg, jpeg, png, bmp, Max. file size: 15 MB.
Your Details
Name
*
Select Title
Mr
Mrs
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Master
Prof
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Title
First Name
Last Name
Address
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Postcode
Email
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Mobile
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Date of Birth
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Biological sex
*
Please select
Male
Female
Ethnicity
*
We collect this information as part of our equality and diversity monitoring
White British
White Irish
White Other
White and Black Caribbean
White and Black African
White and Asian
Other Mixed Background
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Other Asian background
Black or Black British Caribbean
Black or Black British African
Other Black Background
Chinese
Any Other Ethnic Group
I would rather not say
Additional Information
Additional Needs
I require an interpreter
I require a downstairs surgery
Language
*
Please give us details of any ways in which we can meet any additional needs you may have
I would like an appointment with the
*
Treatment co-ordinators are not dentists but are specially trained to discuss treatment options with you before you see a dentist. Alternatively you can have a Free Smile Check (£20 refundable deposit) appointment with a Dental Therapist including a Full Mouth Scan. This is ideal if you’re unsure about the sort of treatments available. If you want to see the dentist there will be a £60 consultation fee which will include full examination and treatment planning.
Free online phone consultation
Scan and Screen (includes FREE 3D scan of your smile, and Dental Photographs)
Dentist Chair Consultation (£60 consultation fee)
Failure to Attend
*
I agree to attend my appointment, and that if I do not give 24 hours notice to cancel the practice may not be able to offer me care in the future.
I agree to attend my appointment
Consent
*
I understand the practice will use the information I have given to contact me about providing dental care and this information will not be shared without my consent unless required by law. I agree this information will be stored on the practice computer systems for the purpose of providing dental care to me.
I agree to the privacy policy.
I would to receive e-mails with practice news and special offers
*
Yes
No