Emergency

Thank you for your urgent enquiry. We will contact you soon.

Your contact details

First name *

Last name *

Date of birth *

Contact number *

Your dental emergency

Are you experiencing dental pain? *

Yes

Do you have a broken tooth? *

Yes

Do you have a lost filling? *

Yes

Do you require an interpreter for your appointment? *

Yes

Please specify language *

Do you have any mobility issues which requires you to be seen in a ground floor or accessible surgery? *

Yes

NHS exemption confirmation

The patient is responsible for the accuracy of this claim, NOT the dental practice. If you’re not certain that you’re entitled to receive free or reduced cost NHS dental services you MUST pay the dental practice. If you subsequently confirm that you were entitled to free or reduced cost dental services, you can claim a refund. If you have applied for a qualifying benefit or exemption certificate but have not received it yet, you must pay and claim a refund when/if you do receive it.

Checks on claims are undertaken to confirm you are entitled. Incorrect claims for free or reduced cost NHS dental services will result in a penalty charge of up to £100, in addition to the cost of NHS dental services. You won’t have the opportunity to pay for the services first to avoid the penalty charge.

Are you entitled to free NHS dental services? *

Yes

I am entitled to free NHS dental services because on the first day of treatment:

I am under 18 years of age

I am 18 years of age and in full time education

I am pregnant

I had a baby in the last 12 months

I am currently in prison or a young offenders institution

None of the above

Enter name of college or university *

NHS Maternity exemption certificate / card no. *

Date baby due/born *

I am entitled to free NHS dental services because during the course of treatment I get, or am included in an award (as a claimant, partner, or dependent person under 20) of:

Income Support (Incapacity benefit and Disability Living Allowance does NOT count)

Income-based Jobseeker’s Allowance (Contribution-based does NOT count)

Income-related Employment and Support Allowance (Contribution-related does NOT count)

Pension Credit Guarantee Credit (Savings Credit on its own does NOT count)

Universal Credit and meets the criteria. Find out more at http://www.nhsbsa.nhs.uk/UC

Person receiving benefit *

Date of birth *

Enter National Insurance Number *

You are not eligible for a NHS Urgent Dental Access Centre appointment but you do qualify for a private emergency appointment and will be redirected to our online booking system. Click below to proceed.

PracticeId

mydentist, Cowpen Road, Blyth Dentist in Blyth

Emergency Triage

Your contact details

Your dental emergency

NHS exemption confirmation