Clear Smiles Orthodontics :: Adult form

New adult patient form

You can either fill in the online form below or print it off at home and fill it in.

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Title*

Gender*

Are you the financially responsible party?*

Do you have Private Health Insurance?*

Does it cover Orthodontics?*

How did you hear about Clear Smiles Orthodontics?*

Adult medical and dental history

Medical checklist. Please mark if you have suffered from any of the following:*

Dental history

Have you had your wisdom teeth taken out?*

Do you currently or have a history of*:

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Note:

- 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.