Name*

Email Address*

Contact Number*

Are you a new or existing patient?*
New PatientExisting Patient

Are you registered under any CHAS schemes or Corporate Insurance policies?*
NoNot SureBlue CHAS cardOrange CHAS cardPioneer Generation cardMerdeka Generation cardAIA InsuranceIHP InsuranceAlliance MedinetFullerton Healthcare (SIA)Allianz CareSAFRA cardOther

Preferred Date*

Preferred Time*
10:00am10:30am11:00am11:30am12:00pm2:00pm2:30pm3:00pm3:30pm4:00pm6:00pm6:30pm7:00pm7:30pm8:00pm

Preferred Branch*
Bedok MallBedok SouthChai Chee 26A684 Hougang681 HougangNew Upper ChangiNorthpoint CityTampines 201DTampines 821Tampines 827Tampines PlazaSingapore Management UniversityCentral Patientcare (Yishun)The Dental Practice @ BedokThe Dental Practice @ TampinesThe Dental Practice @ Paya Lebar

Service*
Braces ConsultationBraces RetieChairside Whitening ConsultationCrownDenturesFilling (Restoration)Gum Treatment (Periodontics)ImplantInvisalign ConsultationNormal ExtractionRoot Canal TreatmentScaling & PolishingVeneer ConsultationWisdom tooth ExtractionOthers

Any Preferred Dentist?*
NoYes (Please specify in Remarks below)

Remarks

Please be aware that your appointment is NOT confirmed until we have contacted you. If you require an urgent appointment, please call our clinics directly.

By clicking the "SEND" button below, you have given consent to Luminous Dental Group Holdings Pte Ltd which agrees to use it accordingly to its privacy policy.