Consent Form

  • DD slash MM slash YYYY
  • hereby give my permission for (Holland Park Dental) to contact me via

  • in connection with my care, appointment times, recall reminders, details of dental treatment/s, and payments.

    Please provide details of which you consent to.

  • Your consent to being contacted is entirely voluntary and you may withdraw your consent at any time. Should you have any questions about this process or wish to withdraw your consent please contact us on 020 7603 4155.

  • eSigned

  • DD slash MM slash YYYY