You must be the Child's Legal Guardian to complete this form. Please confirm you are the Child's Legal Guardian. *

Has a written referral been provided? *

Parent Responsibility *

Is there a Court Order/Pending Court Order/Formal Family Agreement? *

Do you have Private Health Insurance *

Has your child had a previous General Anaesthetic? *

Are your child’s immunisations up to date? *

Please tick the following Medical Conditions that apply to your child *

Is your child currently experiencing any pain? *

Did your child have an accident and injure their teeth? *

By submitting this form I acknowledge, to the best of my knowledge, all the preceding answers are true and correct. I also acknowledge that I am responsible for all fees incurred at the conclusion of each appointment *

I acknowledge this is a Specialist Private Practice and as such Specialist Fees will be charged *

I acknowledge my fees will not be bulk-billed *