You can either fill in the online form below or print it off at home and fill it in.
(Please tick where applicable)
Should you have any medical condition which may require further discussion, please advise.
By submitting this form, you are confirming that to your knowledge, the information provided is complete and correct.
Authority to request/refer records to health care providers
We may need to request records from your previous or current dentist or specialist to assist with your orthodontic planning. We also correspond and forwards x-rays to your dentist or other specialists for treatment planning when required. During your treatment, we may need to refer you to other specialists. To ensure compliance with Federal and State Privacy Legislation we require your signed consent to work with other health care professionals.
Permission to take diagnostic x-rays
Client over 18 to sign OR Responsible Party to sign
See the kinds of issues we have helped resolve for some of our patients in our smile gallery.
We’ll work with your family budget to find the best payment plan for your orthodontic treatment.
Level 15/15 Collins StreetMelbourne VIC 3000Australia
1 Milne St (Cnr Milne and Foote Streets)Templestowe, VIC, 3106Australia