Linda Briggs Ltd Independent Cosmetic Dentistry Advice
 
INITIAL ENQUIRY FORM | fields marked * are required
 
* Salutation:  
* Forename(s):  
* Surname:  
* Postcode:
  * Country:
 
* Home Phone:
  Mobile 1:
 
  Work Phone:
  Mobile 2:
 
* Email Address:  
  Do you smoke?:
  Are you pregnant?:   Age:
 
  Allergies or illness:  
* Enquiry:  
* How did you
find us?:		  
INSTRUCTIONS
Please complete this form ONLY if you are new to Linda Briggs Ltd.
 
Once we have received this form you will be contacted by email or telephone.
 
For ALL general emails use the SEND AN EMAIL form below the link for this form on the previous page. Or call us on:
 
( +44 (0) 1354 610 368
 
 
DENTAL PROBLEMS | use the chart below to identify your teeth
 
  Tell us about your
current situation
by filling in the relevant details
below, using the
numbers on this chart:
▼ Upper Right ▼ ▼ Upper Left ▼
                               
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
▲ Lower Right ▲ ▲ Lower Left ▲
 
 
Missing teeth:

Enter the number(s)
in the correct boxes
Upper Right Upper Left Lower Right Lower Left
 
 
Painful teeth:

Enter the number(s)
in the correct boxes
Upper Right Upper Left Lower Right Lower Left
 
 
Old fillings:

Enter the number(s)
in the correct boxes
Upper Right Upper Left Lower Right Lower Left
 
     
   
 
 
 

Design & Programming by Silicon Fish