Online Claim Form - The Dental Law Partnership

01 Personal Details

Country *

If your enquiry is about a claim, we are only able to process claims for dental negligence that occurred in England or Wales

England or WalesElsewhere

Your name *

Your e-mail address *

Your phone number *

Does the potential claim relate to treatment YOU have received? YES - please go to section 2 'Treatment Information'NO - please fill in the section below

Are you enquiring on behalf of someone else? If so:

What is their name?

What is your relationship to them?

Have you got their permission to speak to us?

What is the format of their permission?

(If written please attached at the end of the form)

02 Treatment Information

What treatment are you complaining about? *

Date of treatment (approximate date if exact date not known) * Location of Dentist/Town *

What injury did you suffer? *

What treatment do you now need? *

How did you find out there was a problem? *

When did you find out there was a problem?
(approx. date) *

Have you attended regular dental check-ups in England or Wales in the last 2 years before the treatment you are complaining about? YESNO

03 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.

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