Family Enquiry Form

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Your enquiry has been sent to our Domiciliary Team. We aim to respond to all enquiries within 1 working day. If this is a dental emergency, please call us. Thank you.

Family Enquiry Form

If you are caring for an elderly, housebound, or mobility-impaired loved one, securing essential dental care can be a challenge. Please complete the brief form below for our assistance.

The patient has capacity to consent

NO - We provide domiciliary care for adults (18+) only. Please contact your local NHS Board for child services.

Your Name

Patients Name

Relationship to Patient

Legal Authority

Select one that applies.

NHS Exemptions

Select an option from the dropdown menu that applies.

Your Email Address

Your Phone Number

Enter your PRIMARY_NEEDS

***Urgent Dental Pain*** This form is not monitored for emergencies. For acute pain, call 0141 489 1789

Data Protection Notice:

The information you provide will be used to respond to your enquiry and manage dental care in line with our Privacy Policy. We will not share your data without a lawful basis.