Denplan for Dentists - Joining Denplan: Membership application

Application details

Have you ever been suspended from practice, refused registration by any registration body, had your name erased from a professional register, had restrictions placed on your registration or been subject to disciplinary action of any kind?: * Yes No

Has any professional indemnity provider ever declined to provide cover, placed special conditions on cover, or cancelled or refused to renew your cover?: * Yes No

If you have answered Yes to the above questions, please provide details:

Is the Practice owned by a company not managed by you and / or part of a Corporate Body?: * Yes No

If yes, please provide name: Which defence organisation you belong to: DPL DDU MDDUS Other If other, please specify:

	About Denplan Careers Feedback Contact us Patients Benefits of Denplan The products Joining Denplan NEW! Your fees explained Find a dentist Already a Denplan member? Denplan Online Services Supplementary Insurance and benefits Complaints procedure Contact Denplan Dentists Benefits of Denplan Joining Denplan The products Our services NEW! Denplan Ireland Decontamination support Dentist news Denplan Events Denplan Excel Denplan Training Denplan Online Services Contact Denplan Company plans For Brokers For Companies For Employees Find a dentist Contact Denplan Schools The plans Prices / payment options For parents / plan members Sign up Contact Denplan About Denplan Timeline Biographies Awards Media centre Latest news Publications Frequently asked questions (FAQs) Contact Denplan Home Dentists Joining Denplan Membership application Benefits of Denplan Joining Denplan Membership application Practice Development Profile (PDP) online Book a consultant appointment Moving from the NHS What our members say Already a Denplan member? The products Our services NEW! Denplan Ireland Decontamination support Dentist news Denplan Events Denplan Excel Denplan Training Denplan Online Services Contact Denplan Membership application The first step to joining Denplan is to fill in your membership application form. The one off cost of membership is £50.00, however you won't be required to pay this fee now, we'll invoice you once you become a member. If you are involved in a goodwill transfer and buying a Denplan practice, please email us at goodwilltransferservice@denplan.co.uk or call on 0800 169 7660. Membership application form Please complete and submit the form below to confirm you membership to Denplan. Please note: All fields marked * are mandatory. Your details GDC No: * Title: * First name: * Surname: * Date of birth: * Gender: * MaleFemale Qualifications: * Telephone No: * Practice name: * Address line 1: * Town: * County: * Postcode: * E-mail address: * Web address: Application details Have you ever been suspended from practice, refused registration by any registration body, had your name erased from a professional register, had restrictions placed on your registration or been subject to disciplinary action of any kind?: * Yes No Has any professional indemnity provider ever declined to provide cover, placed special conditions on cover, or cancelled or refused to renew your cover?: * Yes No If you have answered Yes to the above questions, please provide details: Is the Practice owned by a company not managed by you and / or part of a Corporate Body?: * Yes No If yes, please provide name: Which defence organisation you belong to: DPL DDU MDDUS Other If other, please specify: Application confirmation I hereby apply to become a member of Denplan. I have read and agree to comply with The Denplan Rules. * Complete form Data Protection Act - view Denplan's DPA Statement. If you do not tick the box below, we will assume that you are happy for us to contact you about the products and services. Tick here: To request an appointment with one of our consultants, please complete an appointment enquiry form.

Membership application

Membership application form