This form is for a medical-dental prescription and should only be submitted by, or on behalf of, the treating clinician with a valid GDC registration number.

By submitting this prescription, you are placing an order for a medical, dental appliance and adhering to all GDC and MHRA regulations regarding this. You are also adhering to Ashford Orthodontics Ltd terms and conditions and pricing (full price list on request) including postage or tracked courier charges as below.

Orders will incur a delivery charge of £6.