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Patient application form

In completing this application for Dental Finance I confirm that I have read the ‘Use of Information’ Statement and accept how my information will be used in order to assess my application.

Click here to read our ‘Use of Information’ statement.

(* indicates a mandatory field)

I agree*
Please agree with the statement

Is this application being submitted at the practice?*
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Please complete the application form below. There are several pages in the form, click the next button at the foot of each page to move on to the next one.

Practice details

(* indicates a mandatory field)

Practice name: *
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Practice Tel. No: *
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Supplier No:
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Purpose: *
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Other details, please specify*
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Total price of treatment: *
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Deposit to Practice: *
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If deposit paid, did you use a credit card?
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Amount of finance required:*
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Term: *
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Interest (APR): *
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Monthly repayment: *
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Patient's personal details

(* indicates a mandatory field)

Proof of signature - Main debit/credit card number, first six digits, last four digits:*
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Proof of address (bank or credit card statement/utility bill/driver's licence). Please note date, reference details here: *
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Title: *
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Forename: *
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Other initials:
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Surname: *
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Date of birth: *
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Previous/other name:
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House number/name:*
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Street: *
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Town: *
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Postcode: *
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Preferred telephone contact number*
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Preferred telephone number: *
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Secondary telephone contact number
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Secondary telephone number:
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email address: *
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Have you lived at your current address for more than three years?
Yes/No*
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Number of years at current address:*
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Number of months at current address:*
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Previous house number/name: *
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Previous road: *
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Previous town: *
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Previous postcode: *
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Time at previous address:
Number of years at previous address*
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Number of months at previous address:*
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Marital status: *
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Number of dependents aged under 18:*
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Residential status: *
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Do you have a mortgage?*
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How many years have you held your mortgage?*
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How many months have you held your mortgage?:*
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If homeowner, are you applying for more than £9,000? *
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Current outstanding mortgage: *
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Year of purchase: *
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Purchase price: *
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Applicant's bank details

(* indicates a mandatory field)

Bank sort code: *
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Debit card held: *
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Years with bank:*
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Months with bank:*
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Number of credit cards held: *
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Employment or self employment details

(* indicates a mandatory field)

Your employment status: *
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If part time, you must work at least 16 hours per week.
If you are a house person, please enter your spouse's or partner's details.
Employer's name: *
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Telephone number: *
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Years with employer:*
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Months with employer:*
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Job title: *
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Employer's address:
Building number/name: *
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Branch/department:
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Street:*
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Postcode or town:*
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Current salary: *
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Gross annual income: *
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Self employed address
Business name: *
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Business Telephone number:*
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Type of business: *
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Years self employed: *
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Months self employed:*
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House or building number: *
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Street: *
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Town: *
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Postcode: *
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