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Patients Name*

Parent of Guardians name (if under 18)

Email Address*

Address

Date of Birth

Dentist (If Applicable)

Please tick a box to indicate where you would like to have your treatment. Tick both boxes if you want the soonest appointment in Gorey with either Dr. Butler or Dr. Ryan. Tick all 3 boxes if you want the soonest appointment anywhere. Please note that you will not be able to change orthodontist once your treatment has started.

 Wexford (Dr Ryan) Gorey (Dr Ryan) Gorey (Dr Butler)