Clear Smiles Orthodontics :: Child form

New child patient form

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

Download form


Responsible party 1 information (for billing purposes)*

Responsible party 2 information (for billing purposes)

Are you the best person to contact regarding appointments?*

Do you have private Health?*


Do you have Private Health Insurance?*

How did you hear about Clear Smiles Orthodontics?*

Child 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*:

Please sign here:

By submitting this form you are agreeing to our privacy policy, Click here to read.


- 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.