Dental Negligence Form

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Surname(*)

Please let us know your surname.

First name(*)

Please let us know your first name.

Title(*)

Please select one of the titles

Address(*)

Please enter your address

E-mail

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Telephone number(*)

Please let us know your phone number.

Date of birth(*)

Please enter your date of birth

Occupation(*)

Please enter your occupation or 'n/a' if not applicable

National Insurance No

Please enter your national insurance number or 'n/a' if you don't remember yours

When did you seek dental advice?(*)

Please let us know the date you saught dental advice

From whom did you seek dental advice?(*)

Please let us know where you received dental advice/treatment

In your opinion, how did the alleged negligence occur?(*)

Please let us know how the negligence occured

What exactly happened?(*)

Please let us know what happened

Have you recovered from the effects of the treatment?(*)

Please let us know if you have recovered from the effects of the treatment

If no, what is the present position?

Did you require any time off work? (*)

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Name of GP & Address(*)

Please enter your GP's details

Was the treatment private or on the NHS?(*)

Please let us know if this was private or NHS treatment

If privately, with whom are you insured?

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Do you have any legal expenses insurance as a part of any home contents or building insurance?(*)

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How did you hear of Simon A Holt & co?(*)

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Dental Negligence Claims Form