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NHS DENTAL CARE
Contractor's Name: Handan Sabahtar Patients Surname: Markandu
Address: Inspire Dental Walthamstow Patient's Forename: Mathiyalagan
67-69 Palmerston Road
Walthamstow Date of Acceptance: 22/03/18
London Treatment on Referral: No
Telephone: 0208 521 6656
NHS Organisation: NHS England London Lat _____________________

TREATMENT PLAN & ESTIMATE Revision No.
What the NHS The NHS provides alt the treatment necessary to secure and maintain your oral health. there are; some treatments (mainly construe) that are not normally available
will provide under the NHS. and you may choose to have these provided privately. You may also choose to have some treatment provided privately AS an alternative to
NHS Treatment. The dentist vv<R discuss these options with you so that your car; mate an informed choice.
Emergency Whenever possible please contact us about urgent treatment during normal surgery hours. 1 you need to be seen the same day. please get in touch as early in the day as
possible.
Arrangements It an emergency wfeoa out of hours, please telephone the Primary Care Trust for advice
Replacements if you are 18 or over and a root filling, veneer, inlay or crnvjt prowled by to« under the NHS within the last 12 months has to be replaced, you will not be charged If
free of you return to OTB, untessr-
change Thu treatment was ferrporary; or it was provided against my advice; or the replacement is necessary because of accident; or a different treatment is necessary because a
satisfactory replacement Is not possible
This NHS cover doo« not apply to any private treatment you may have.
I Dental treatment I want you to tunterstard the treatment being offered and any charge wfwch may app-'y. Sekrw is a treatment plan and at estimate of the cost Within 2 norths of completion ch8fg&S
of the course of treatment twfow, should you require ft*ther NHS treatment in either Ihe same or tov*ar charge band. you vrfl not normally need to pay again
Plooso ask tf you do not understand thl* or need any further infurrrwrtwv
Treatment Off with your agreement, it may be riocossary to refer you to another dontist under NHS arrangements, for part of your course of NHS danW treatment Where this happens
referral you vail not be asked ta pay a further charge tor your NHS dental treatment: only one charge v*ill be made by your referring dentist, as outlined below.
Paying for Patients aged t8 and over normally pay charges for MHS treatment. TTero is NO CHARGE If you are;
NHS treatment * Pregnant or have had a child in the last 12
months *tf you are aged 18 and in full time
education
* If you or your partner are named on a current HC2 NHS charges certificate
* if you or your partner we named on a valid NHS lax credit exemption corticate
* if you or your partner receive Income Support. Income-based Jobseeker's Allowance or Pension Credit Guarantee Credit
If you are not In any of these groups, but have a tow income, you may still be a We to get help ratth NHS charges. You can get a claim form HC1 from any Sodal
Security office Please Note; The following benefits, on their own, do not orttttte you to help vrfth health costs: Incapacity Benefit Disability Living Allowance, PensIOA
Credit Saving* Credit and Couth bull on bused Jotrteefw'S Allowance.
Cancelling If you have to cancel an appointment, please give as much notice as possible In order lhal it may be offered to someone else IF you miss appointments I may be unable to
Appointments provide further treatment.
Regular care Taking good care of your teeth Is important. Come and see me regularly for check-ups and advice. Some people need to see their dentist more* than orhors and f shall ouvsea you
when to return next
NHS Treatment 1
Examination
1 Extraction LR1
1 Extraction LL1
1 Extraction LL2
1 Partial Denture Bearing LR1-LL2
1 Primary Denture Impression(s)
1 Note

Total £ 0.00
Additional Private Treatment £ 47.00
1 30 minHygienist Visit Total £ 47.00

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