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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)

I agree*
Please agree with the statement

Is this application being submitted at the practice?*
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Please complete the application form and then click on 'submit' on the final page.

Practice details

(* indicates a mandatory field)

Practice name: *
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Practice Tel. No: *
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Supplier No (if known):
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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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Repayment term: *
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Interest (APR): *
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Monthly repayment: *
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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.

Proof of signature- please confirm what card you will present by typing in the first 6 digits and the last 4 digits of your card number in this box.*
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Proof of address - please confirm what you will present. It can be one of the following - Driver's licence (type in licence number), Bank or Card statement (type in Bank name and date), Utility or Council tax bill (type in Provider/Council name and date).*
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Title: *
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Forename: *
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Other names:
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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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Time at current address - years  *
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Months*
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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 - years  *
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Months*
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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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Time you've held your mortgage - years  *
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Months*
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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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Time with bank - years  *
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Months*
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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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Time with employer - years  *
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Months*
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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 annual income: *
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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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Time self employed - years  *
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Months*
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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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