Request An Appointment

(Copy): ** Please note that the below form is to request a call back from a member of our reception team to organise an appointment booking.
If your appointment request is urgent, calling the clinic on (08) 8258 2278 will enable staff to assist you in a more timely manner **
Who is this appointment request for?:: MyselfSomeone else
Have you been to Salisbury Dental Care before?:: YesNo
Briefly describe the reason for your appointment:
Name:: First Name:
Last Name:
Contact phone:
Email Address:
Date of Birth:
: (Why do we ask this question? – we sometimes have people with the same or similar names so having a date of birth confirms if we have your correct records)
Do you have a dental cover through a Health Fund?:: YesNo
If you answered yes, what is the name of the Health Fund?:
Preferred appointment date:
Preferred appointment time:
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