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Children Registration
NHS Children Sign Up
Please complete the form below, for any child under the age of 15 years of age, who you wish to register for care at Breeze Dental.
Our reception team will make them an appointment and send you the details by text.
Please note after-school appointments are very limited and so your child's appointment will almost certainly be during school hours. All Sunderland schools are aware of this and are aware their pupils may need to be taken out during school hours for dental appointments.
Thank you!
*
1.
Name
(Required.)
*
2.
Date of birth
(Required.)
3.
Address
4.
Post code
*
5.
Telephone Number
(Required.)
*
6.
Email address
(Required.)
*
7.
Dr details (including practice)
(Required.)
*
8.
Next of Kin details
(Required.)
*
9.
Best day of the week
(Required.)
Monday
Tuesday
Wednesday
Thursday
Friday
10.
Where did you hear about us?