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Menu
About Go
Leisure Travel
How It Works
Cover Options
Medical Conditions
Sports & Leisure
FAQ’s
Non Resident
Australians Already Overseas
Non-Resident Travel Insurance
Specialist Covers
Cruise
Destination Wedding
Dental Tourism
Sailing
Golf
Snow Sports
Water Sports
Business
Corporate Travel
Group Travel
Contact Us
Claims
Request a Cancellation
Request a Policy Extension
Request a Trekking Quote
Travel Alerts
Latest Travel Alerts
Smartraveller Warnings
Get a Quote
Dental Form
Dental Tourism Quote Application
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
We require a dental plan in place prior to being able to offer a quote.
Please upload your dental plan.
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.
How did you find out about the Dental Tourism cover offered by Go Insurance?
*
(ie Travel Agent, Google, Friend)