Fix my smile
(07) 5593 3733
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?*
Does your policy cover dental?*
How did hear about Clear Smiles Orthodontics?*
Medical checklist. Please mark if you have suffered from any of the following:*
Have you had your wisdom teeth taken out?*
Do you currently or have a history of*:
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Where do we go from here?
Come and talk to us, show us your teeth and see what we can do to help. It'll cost you absolutely nothing!
Book a free consultation
Suite 1 (Ground Floor) 2 Investigator Dr