Membership application form

The first step to joining Denplan is to complete your membership application form.

If you are involved in buying a practice with Denplan patients, please email us at: goodwilltransferservice@denplan.co.uk or call on 0800 169 7660.

Please note: fields marked Required Field Indicator must be completed

Your details

GDC No. Required

Title Required

First name Required

Surname Required

Date of birth Required

Gender Required

Professional qualifications Required

Telephone No. Required

Practice name

Address line 1 Required

Town Required

County Required

Postcode Required

Email address Required

Website

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?

Has any professional indemnity provider ever declined to provide cover, placed special conditions on cover, or cancelled or refused to renew your cover?

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?

If yes, please provide name

Which defence organisation do you belong to

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.

Please read Denplan's Data Protection statement.
We may contact you about the products and services which we feel may be of interest to you, by post or by telephone. Please tick the box if you do NOT wish us to do this. Please tick the box if you WOULD like us to contact you by email with information about goods and services which we feel may be of interest to you.

Complete form

New to Denplan

Membership application form

Thank you for applying to become a Denplan member.