Dental Form

Name*
First Last
Age*
Email*
Date of Departure from Australia*
Date Format: DD slash MM slash YYYY
Date of Return to Australia*
Date Format: DD slash MM slash YYYY
Facility where treatment will be performed*
Do you have a treatment plan?*
- Yes
- No
Details of Procedures to be Performed*
ie - 3 Implants : 2 Crowns : 4 Fillings
Scheduled procedure start date*
Date Format: DD slash MM slash YYYY
Cost of procedure*
Nature and dates of follow-up treatment (if applicable)
Do you have a usual dental practitioner in Australia?*
- Yes
- No
If yes, please provide the name and address of usual dental practice in Australia
Have you consulted this practitioner in respect of the abovenoted procedure?*
- Yes
- No
Have you had any previous treatment for the abovenoted condition?*
- Yes
- No
If yes, please provide details.
Have you had any other elective and / or cosmetic dental procedures?*
- Yes
- No
If yes, please provide details.

Go Insurance is a registered trading name of Go Unlimited Pty Ltd (ABN 74149217925) AFS License no 404782 of PO Box 5964 Brendale 4500.

1300 819 888