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NHS Disclaimer:

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.


NHS Number





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






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






c) I am entitled to free NHS dental services because I was named on one of the following certificates that is valid during the course of treatment:



d) I am entitled to reduced cost NHS dental services because:


Supporting evidence





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Date Treatment Price
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Date Treatment Price
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Patient:

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Treatment Qty



  • NHS Notes


Patient: Date Acc.: Date Compl.: Band:

    Recall
    Best practice prevention offered
    Referral for advanced mandatory services
    Continuation within 2 months

    Perm. Deci. Perm. Deci. Perm. Deci.
    Decayed:           Missing:           Filled:     

     
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    Patient:

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