Online Claim Form

1. Personal Details

Name *

? Your name will be used for customer service purposes.

Email *

? If we are unable to contact you by phone we can email you to help and to provide important information about your claim. (We will never sell your information to third parties.)

Phone *

? This number will be used for the purposes of customer service and to provide important updates about your claim.

Does the potential claim relate to treatment YOU have received? yesno Are you calling on behalf of someone else? If so: What is their name? What is your relationship to them? Have to you got their permission to speak to us? yesno What is the format of their permission? (If written please attached at the end of the form) writtenverbal

2. Treatment Information

Date *

Name of the Dentist *

? This information will be used for the initial assessment of your potential dental claim.

Location of Dentist* What treatment are you complaining about? *

? This information will be used solely for the purpose of assessing whether you have a potential dental claim.

What injury did you suffer? *

? We collect this information for the purpose of assessing whether you have a potential dental claim.

What treatment do you now need? *

? We collect this information or the purpose of assessing whether you have a potential dental claim.

When did you realise there was a problem? * How did you find out there was a problem? * Have you been a regular dental Patient in the last 3 years? yesno Have you made or received any offers of settlement in relation to your complaint? yesno

Please take a few moments to read this important information before you complete our online claim questionnaire.

We are a firm of solicitors registered to act for clients in England and Wales. If your dental treatment took place outside these areas please contact us for advice before completing this form.

There are time limits in bringing a case against a dentist and the clock starts from when you knew about your problem. If this was more than 3 three years ago we probably cannot assist you in bringing a claim but please contact us for advice before completing this form.

As regulated solicitors we work under strict guidelines and for this reason we will need to know if another firm of solicitors has worked for you on this potential claim for more than a month. If this is the case then please contact us for advice before you complete our claim check form.

I have read the above *

3. Extra Information

How did you find out about Dental Law Partnership? * If you have any documents you wish to provide with your claim form please attach them below.

? These documents will be used as supporting evidence of your potential claim.

I confirm that the information contained within this questionnaire is true to the best of my knowledge and belief. *

Enter the code to continue I have read and agreed the privacy policy *

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