You may be eligible for free dental care if you are registered/enrol with us!
More info please click here
Secondary School / Education institution to be attended: Name of school*National Health Index (NHI): NHI*
Check any of the following medical conditions that you have had or have at the present:
For patients with special needs, cognitive issues, or physical disabilities, please complete an additional special dental care form.
If you have any questions about this form or are unsure how to answer any questions, we are happy to assist.
Authorization: I have reviewed the information on this form, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.