Adult Patient form | Clear Smiles orthodontics

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 responsible party?*

Do you have private Health?*

Does your policy cover dental?*

Orthodontics?*

How did 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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