You can either fill in the online form below or print it off at home and fill it in.
Are you the financially responsible party?*
Responsible party information*
Do you have Private Health Insurance?*
Does it cover Orthodontics?*
How did you hear about Clear Smiles Orthodontics?*
Medical checklist. Please mark if you have suffered from any of the following:*
Have you had your wisdom teeth taken out?*
Do you currently or have a history of*:
Please sign here:
- Current Medicare Card required to bulk bill x-rays or $100 fee.
- Private health insurance - we claim only what the insurance contributes towards the initial consultation, waiving any out of pocket expenses.
connect with us
Suite 1 (Ground Floor), 2 Investigator Dr, Robina, QLD 4226