You can either fill in the online form below or print it off at home and fill it in.
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 Insurance?*
Does it cover Orthodontics?
Do you have any siblings?
How did you hear about Clear Smiles Orthodontics?*
Medical checklist. Please check the box if you suffer 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