Dental Form

PERSONAL DETAILS

Applicant’s Name

Age

Email address

Phone number

ITINERARY DETAILS

Travel Dates
from: to:

Name of tour facilitator

Name of accommodation provider

PROCEDURE DETAILS

Details of condition being treated

Details of procedure to be performed

Scheduled procedure date

Facility where treatment will be performed

Name of treating practitioner

Cost of procedure

Nature and dates of follow-up treatment

DETAILS OF YOUR USUAL DENTAL PRACTITIONER IN AUSTRALIA

Name

Address

Have you consulted this practitioner in respect of the abovenoted condition?
 yes no

If yes, does this practitioner recommend the procedure noted above?
 Yes No

Is this practitioner aware that you are travelling overseas to receive treatment?
 Yes No

Have you discussed the likely success of the procedure with this practitioner?
 Yes No

If yes, what advice / recommendations did this practitioner provide?

Have you had any previous treatment for the abovenoted condition?
 Yes No

If yes, please provide details

Have you previously had any other elective and / or cosmetic dental procedures?
 Yes No

If yes, please provide details

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