Book an Appointment | Bright Smiles Dental Care

Call Us: 03 351 7700

Patient Information

Please enter your child’s information below as a reference for us.

Preferred First Name

Date of Birth*

Gender*

Contact Information

Parent/Guardian contact information for correspondence.

Parent(s)/Guardian(s)*

Address

Phone (Home)*

Phone (Work)*

Phone (Mobile)*

Phone (Other)

Email*

Preferred Contact*

Phone

Text

Booking Details

Type of Appointment*

A checkup is part of your regular dental care that normally happens annually or six monthly.

A consultation is because you’ve been seen by someone else and referred or there’s a particular issue that you’d like looked at.

If neither of the above are quite right, select ‘Other’ and let us know what you need in the ‘Other Info’ field.

Let us know what you need

Have you been referred or are you referring yourself?*

We are more than happy to see you without a referral, but we'll get a bit of detail off you soon.

Who have you been referred by?*

Clinic

Referral Number

What is the reason for the consultation?*

Who would you like to see?*

What days suit you?*

Monday

Tuesday

Wednesday

Thursday

Friday

What times suit you?*

8:30 - 10:00am

10:00am - 12:30pm

1:30 - 3:00pm

3:00 - 5:00pm

Anything else you'd like us to know?

We’re open Mon-Fri 8am-5pm

214 Papanui Road, Merivale, Christchurch

Ph: 03 351 7700

Email: hello@brightsmiles.nz

214 Papanui Rd
Merivale
Christchurch
P. 03 351 7700 E. [javascript protected email address]

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