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Please Note! This form is for Registered Patients of the Dr BK Clinic. You can Register Here >>

Book An Appointment at The Clinic:

1. Your Personal Details:



If for any reason you need to cancel your appointment, we require a minimum of 48 hours notice.

Call us on: 0118 960 6930 or
Email: info@drbk.co.uk

If you are experiencing dental pain which can’t be relieved by taking an over-the-counter painkiller, or you require emergency dental treatment out of hours, please call the practice and listen to our recorded message.

Tel: 07905 000537

Please enter your personal information below:

First Name:

Surname:

DOB (dd/mm/yy):

Address:

Post Code:

Contact Number:

Email Address:

Notes/ Comments:

2. Select Required Treatments:
Please tick the following treatment(s) you would like to book in for your appointment:

Dental Treatments:
Cosmetic Dentistry:
Dental Implants:
Dental hygiene:
General Dentistry:
Oral Surgery:
Orthodontics:
Smile Design:
Tooth Whitening:
Facial Treatments:
Botulinum wrinkle treatment:
Dermal Filler treatment:
Skincare & Beauty:
Facial Treatments:
Foot Treatments:
Hand Treatments:
Massage:
Skin peels:
Tinting:


3. Preferred Booking Time:
Please choose 3 alternate options for your appointment:

1st Choice:
Day: Time:
2nd Choice:
Day: Time:
3rd Choice:
Day: Time:

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