British Homeopathic Dental Association         BHDA
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DETAILS FOR INCLUSION IN THE MEMBERSHIP LIST AND WEBSITE

 (If you do not wish to have your details published on the Web, please still fill up the form but indicate here Yes publish or No do not publish. Delete as applicable )

First Name(s)………………………………...........

Second or Family name………………………………………

Qualifications………………………………………………………………

Address…………………………………………………………………………..

…………………………………………………………………………………….

……………………………………………………………………………………..

Post Code………………………………….

Phone / Fax……………………………………………….

Website / email……………………………………………

Have you attended any courses in Homeopathy ? Yes / No

Are an Associate / Licenced Associate of the Faculty of Homeopathy? ( Delete as applicable)

Is your practice Private , NHS , Mixed ( delete as applicable)

Is your practice mercury free Yes / No

Special fields of interest……………………………………………………………

Are you a dentist / hygienist / Student ?

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