New child 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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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?*

Does your policy cover dental?*


How did 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*:

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