Name

Contact Number

Email Address

Did the treatment take place within the last 2 years? Did the treatment take place within the last 2 years? Yes No

Was the treatment carried out in England or Wales? Was the treatment carried out in England or Wales? Yes No

Have you already made a claim? Have you already made a claim? Yes No

Do you know the name of the dentist and surgery where the treatment took place? Do you know the name of the dentist and surgery where the treatment took place? Yes No

Have you been attending for regular 6 monthly visits in the last 3 years? Have you been attending for regular 6 monthly visits in the last 3 years? Yes No

Briefly describe what went wrong