<%@LANGUAGE=VBScript%> <% if Request.QueryString("act")="mail" then chkPatient=Trim(Request.Form("chkPatient")) txtName=Trim(Request.Form("txtName")) txtHome=Trim(Request.Form("txtHome")) txtMobile=Trim(Request.Form("txtMobile")) txtOffice=Trim(Request.Form("txtOffice")) txtEmail=Trim(Request.Form("txtEmail")) txtCity=Trim(Request.Form("txtCity")) txtPostal=Trim(Request.Form("txtPostal")) txtCountry=Trim(Request.Form("txtCountry")) txtReferral=Trim(Request.Form("txtReferral")) chkOption=Trim(Request.Form("chkOption")) chkSecond=Trim(Request.Form("chkSecond")) txtPlease=Trim(Request.Form("txtPlease")) txtTime=Trim(Request.Form("txtTime")) txtDay=Trim(Request.Form("txtDay")) chkHome=Trim(Request.Form("chkHome")) chkOffice=Trim(Request.Form("chkOffice")) senderaddress="info@kensingtondental.com" sendername=txtName recipientaddress="info@kensingtondental.com" subject="OnLine Patient Appointment Scheduler Form" messagebody = "" messagebody = messagebody & "PATIENT APPOINTMENT SCHEDULER

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PURPOSE OF DENTAL VISIT" & "

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PREFERRED DAYS AND TIMES OF APPOINTMENTS" & "

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APPOINTMENT CONFIRMATION" & "

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General Dental Enquiry

Please contact me as I wish to make an appointment for a Consultation with Kensington Dental Spa
I understand that a standard initial consultation fee of 49.95 GBP applies to include simple scale and polish also relevant x-rays and cosmetic consulatation. An extended consultation or standard Saturday appointment is £64.95.
A comprehensive estimate will be provided prior to any treatment.

Please fill in the form and we will contact you as soon as possible
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PATIENT APPOINTMENT SCHEDULER
* Indicates field is required
Active Patient New Patient
 Name: * 
 Home Phone: 
 Mobile Phone: 
 Office Phone: 
 Email: 
 City: 
 (postal code): * 
 Country: * 
 Referral Source: 
PURPOSE OF DENTAL VISIT
(you may select more than one choice):
Emergency appointment(best to phone)New Patient Consultation
Pain ReliefBroken or missing teeth
Cosmetic DentistrySculpting (reshaping teeth)
Cosmetic VeneersTooth Whitening
Cosmetic CrownsLumineers
InvisalignMaxi / Mini Dental Implants (same day implants)
CEREC (same day teeth)Bicon Dental Implants
NeuroMuscular DentistryNeuroMuscular Dentistry
Oral Surgery / wisdom tooth extractionMouthguard / Clench Inhibitor
Periodontal (gum) therapy or surgeryRoot canal therapy
DiagnosisSecond Opinion
 Please provide more details in the box below:
 

PREFERRED DAYS AND TIMES OF APPOINTMENTS
Office hours: Monday - Friday, 9:00 AM - 17:30 PM (last appointment)Saturday 10:00 AM - 14:00 PM by arrangement (Please give several choices):
 Preferred Time of Day: * 
 Preferred Days and/or Dates: * 
APPOINTMENT CONFIRMATION
(Preferred method to receive your appointment confirmation) :
* One appointment confirmation method is required
Home Phone Office Phone
This Patient Appointment Scheduler will help us to book your appointment with the dentist at a time most suitable to you according to availability.In case of emergency please call the practice on T: 020 7937 3951
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