Name: Warrnambool Orthodontic Hub
Telephone: (03) 4505 2524

Are you covered for Orthodontic Treatment by private health insurance?*

Yes No

If so, name of Insurer:

Has the patient had an orthodontic consultation before?*

Yes No

If “yes”, with whom:

Has the patient ever had orthodontic treatment? *

Yes No

If “yes”, with whom and what was the treatment?

Have you had any problems with dental treatment? *

Yes No

If “yes”, please describe

Have any other family members had orthodontic treatment with us? *

Yes No

If “yes”, what is the patient’s name?

I understand that the above information will be kept strictly confidential.

Ready to transform your smile? Contact us!

Our team can’t wait to put a smile on your face.

171a Liebig St,
Warrnambool VIC 3280

New patient form