Please enter your details into this form. We will be sent an email from this site. You will need to book with us by calling 626 6622 or go to the book online page. Thank you.
Please enter your full name
Please enter your date of birth, D/M/Y
Click to enter an email address
Click to enter mobile phone number
Click to enter home phone number
Please enter you home address
How did you find our practice?
Do any of these options apply to you? Please check appropriate box.
Please list any ALLERGIES you have.
Please list any medications you are taking.
Who is your medical GP?
Please list any other medical conditions that may be relevant to your dentist.
574 Hillsborough RoadLynfield, Mt RoskillAuckland 1041
email@example.com 626 6622Tue- Fri( from 9:00am to 5:00pm )Sat (9:00am to 3:00pm)
© Copyright 2017, Lynfield Dental Centre limited