Dental Form

Name*

First

Last

Age*

Email*

Date of Departure from Australia*

Date of Return to Australia*

Facility where treatment will be performed*

Do you have a treatment plan?*

Details of Procedures to be Performed*

ie - 3 Implants : 2 Crowns : 4 Fillings

Scheduled procedure start date*

Cost of procedure*

Nature and dates of follow-up treatment (if applicable)

Do you have a usual dental practitioner in Australia?*

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?*

Have you had any previous treatment for the abovenoted condition?*

If yes, please provide details.

Have you had any other elective and / or cosmetic dental procedures?*

If yes, please provide details.

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