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Your details

Your Name(Required)

First name Middle Name Last Name

Your Email Address(Required)

Your Phone Number(Required)

NI number(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Your Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Length of time at address(Required)

Nationality(Required)

Emergency contact name/relationship and number(Required)

Are you currently employed as a dental nurse?

Name

Practice address

Are you looking for Full or Part time work? (Min 16 hours required to complete the course)

Are you currently vaccinated against Hep B?

Have you had a DBS check carried out?

Do you consider yourself to have any learning difficulties?

Why do you want to become a dental nurse?

Have you ever been enrolled on another Dental Nursing Course?

Please state which provider and your reasons for leaving

Where did you hear about us?(Required)

Upload photo ID(Required)

Drop files here or

Max. file size: 20 MB.

Upload your CV(Required)

Max. file size: 20 MB.

Medical questionnaires

Are you...

Attending or receiving treatment from doctor, hospital, clinic or specialist?

Yes

No

Details

Taking any medicines from your doctor? (tablets, creams, injections, other)

Yes

No

Details

Taking or taken steroids in the last two years?

Yes

No

Details

Allergic to any medicines, foods or materials?

Yes

No

Details

Have you...

Had Rheumatic fever or Chorea (St.Vitus dance)?

Yes

No

Details

Had jaundice, liver, kidney disease or hepatitis?

Yes

No

Details

Ever been told you have a heart murmur or heart problem,angina, blood pressure, heart attack?

Yes

No

Details

Had any infectious diseases (including Hepatitis & HIV)?

Yes

No

Details

Had a bad reaction to a general or local anaesthetic?

Yes

No

Details

Been hospitalised?

Yes

No

What for

Do you...

Have a hip replacement?

Yes

No

Details

Have a pacemaker, or have you had any form of heart surgery?

Yes

No

Details

Suffer from hay fever, eczema or any other allergy?

Yes

No

Details

Suffer from bronchitis, asthma or any other chest condition?

Yes

No

Details

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Payment Amount

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Payment Amount

Terms and Condition(Required)

Please read in full and tick the terms and conditions

I agree

If paying by installments your £210 will be collected for the next 10 months.

Data protection act notice(Required)

The information given on this application form will be electronically stored and used for administrative purposes by the organization in accordance with the provisions of the Data Protection Acts 1994 and 1998. The organisation may send you details of relevant courses and qualifications including services that may interest you. Please confirm you have read this information and that you accept out privacy policy.

I Agree

Declaration(Required)

I have checked all the details given in this application form carefully and give my consent to Dental Nursing Academy to record and process the information which I declare to be accurate.

I Agree

I agreed with terms and condition(Required)

Please click and read the terms and conditions which is signed by authority. By writing your e signature and submitting the form confirms you are agreed with our terms and condition.

Signature by Laura (Managing Director) dentalnursingacademy.co.uk

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Dental nursing academy

L3 Diploma in Dental Nursing

New Online Dental nursing qualification going live early 2025.

Register your interest now or Enroll today places filling fast..