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    Date of Birth

    Date of Last visit to a dentist

    I have NHS exemption:

    [group nhs_exemption_selected]

    I am entitled to free NHS dental services because on the first day of treatment:

    [group above-18-in-full-time-education-selected]

    [/group]
    [group maternity-ex-no]

    [/group]
    [group had-baby-in-last-12-months-selected]

    Date on which baby born

    [/group]
    [group i-am-pregnant-selected]

    Date on which baby is due

    [/group]

    I am entitled to free NHS dental services because during the course of treatment I get, or am included in an award (as a claimant, partner, or dependent person under 20) of:

    [group ni-no]

    [/group]
    [/group]

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