Dorset House Well Kept

All Instructions are supported by the Direct Debit Guarantee. In order to set up a Direct Debit online you must be the account holder of a personal or business bank or building society account.

Name: Dorset House Dental

Address: 9 Whitehall Road, Rugby, Warwickshire, CV21 3AE Tel: 01788 543217

Plan Specifics - £19.75 per month

Please choose(Required)

I am an existing patient

I am a new patient and understand I need a new patient exam at £50 before joining the plan

Please choose(Required)

I would like to add Worldwide Accident & Emergency cover for 85p per month

I would NOT like to add Worldwide Accident & Emergency cover

Contact Information

Name(Required)

Title First Name Surname

Date of birth(Required)

Address(Required)

Street Address Address Line 2 City Postcode

Telephone Number(Required)

Email(Required)

DATA PROTECTION: The information on this form contains your personal data. Smilecare Limited processes and holds your personal data on behalf of the practice in accordance with the General Data Protection Regulation 2018 (GDPR). Your personal data will only be used by Smilecare Limited in the administration of your dental plan and for no other purpose and by no third party.

DEMANDS AND NEEDS STATEMENT: The Supplementary Insurance policy is designed to meet the demands and needs of patients who require insurance cover for treatment costs arising from dental injury or emergency. The policy is an add on to your dental plan, and is not mandatory. No recommendation has been made in connection with this insurance policy. If you wish to remove the insurance at anytime please contact Smilecare. This will reduce your monthly payments by £0.85 if you opted in beforehand

DECLARATION: I am a patient of Dorset House Dental and request Smilecare Ltd to collect direct debits as detailed above. I understand that Smilecare Ltd (on behalf of Dorset House Dental) is the administrator of the payment scheme and the responsibility for my dental care remains with my dentist. I confirm that I have read and now fully understand the explanatory brochure and the Supplementary Insurance Policy.

I understand that the plan is for a minimum of 12 months and will continue to roll month on month thereafter until cancelled. I understand that I must inform Smilecare Limited of any changes to personal details and if I wish to cancel the plan.

Payment Information

Registration Fee: £12.00

Direct Debit Monthly Fee: £19.75

Your payment will be taken on the first working day of the following month.

Instruction to your Bank or Building Society to pay by Direct Debit

Account holders name(Required)

Account number(Required)

Sort code(Required)

Bank or Building Society Name(Required)

Bank or Building Society Address (if unknown type N/A)(Required)

Street Address Address Line 2 City Postcode

The Direct Debit Guarantee

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
If there are any changes to the amount, date or frequency of your Direct Debit SMILECARE LTD will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request SMILECARE LTD to collect a payment, confirmation of the amount and date will be given to you at the time of the request
If an error is made in the payment of your Direct Debit, by SMILECARE LTD or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when SMILECARE LTD asks you to.
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.