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Patient application form

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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.

(* indicates a mandatory field)

Please agree with the statement

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Please complete the application form and then click on 'submit' on the final page.

Please give us details of the practice where you will receive treatment

(* indicates a mandatory field)

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Your details

(* indicates a mandatory field)

As part of the process your practice will need to verify your signature and address. There is no need to try to attach any documentation to this application.

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If you would like to e-sign the Credit Agreement please provide the following information:

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Have you lived at your current address for more than three years?
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Applicant's bank details

(* indicates a mandatory field)

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Employment or self employment details

(* indicates a mandatory field)

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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.
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Employer's address:
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Self employed address
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