Set up a mandate

For practitioners to set up a Mandate

Please use the form below to register for our website AND set up your mandate. If you already have your mandate set up or you are a DCP you can use the register for website page.

Please email secretary@forthvalleyldc.org.uk if you have any issues registering.

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Your details - setting up your website account

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Username(Required)

Password(Required)

Enter Password Confirm Password

Setting up your mandate

Authority to deduct contributions by Mandate

To: Forth Valley NHS Board

I, the undersigned

Full name (As appears on GDC register)(Required)

First Last

GDC Number:(Required)

List number(s) held with Forth Valley Health Board(Required)

Please detail all your list numbers.

GDC Registered Address(Required)

Street Address Address Line 2 Town/City Postcode

I hereby authorise you to deduct a sum, not exceeding 0.125 per centum per annum from my National Health Service remuneration being the amount which I agree to contribute towards the financing of the functions of the General Dental Practitioners Sub-Committee and of the Local Dental Committee of the Forth Valley Health Board Area.

Please confirm

I confirm that I am authorising you to instruct PSD to take a levy from my NHS Schedule each month.

Signature

Set up a mandate

For practitioners to set up a Mandate

Your details - setting up your website account

Setting up your mandate

Authority to deduct contributions by Mandate

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