Clear Smiles Orthodontics :: Medical form

New Patient Medical 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 Insurance?*

Does it cover Orthodontics?

Do you have any siblings?

How did you hear about Clear Smiles Orthodontics?*

Child medical and dental history

Medical checklist. Please check the box if you suffer 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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- 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.