Workplace Dental Expression of Interest form

Dental On Demand provides mobile dental services to Workplaces. Please fill in the below form to express your interest in a dental visit. Our friendly staff will be in touch with more information.

First name

Last name

Birthday

Day

Month

Year

Gender

Male

Female

Other

Phone

Home Address

Company name

Workplace Address

Are you experiencing any urgent or serious dental issues that need immediate attention? If so, please provide further details.

CONSENT tick yes/no

YES, I give both financial and treatment consent

No, I do not give consent

By submitting this form, you acknowledge and consent to Dental On Demand collecting your personal and health information in accordance with the Privacy Act 1988.

Your information is stored securely and used only for the purpose of providing dental treatment, administrative communication, billing and appointment recalls. You confirm you are the authorised to provide this information and consent to us contacting you regarding your care.

For further info, please see our Privacy Policy.

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Workplace Dental Expression of Interest form