We will be closed from 20th December and will re-open on 5th January, 2026. In an emergency, please contact our Geelong clinic on 03 5221 6677. We wish you and your families a safe and very Merry Christmas and a Happy New Year!

Geelong

(03) 9748 9224

Hoppers Crossing

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Geelong (03) 5221 6677

Hoppers Crossing (03) 9748 9224

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Name: Braces N Faces Orthodontics
Telephone: (03) 5221 6677

Please complete the below forms before your consultation so we can have this information ready before you begin treatment. If you have any questions, please call us on (03) 5221 6677 (Geelong) or (03) 9748 9224 (Hoppers Crossing).

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Patient Information
Medical Forms

Fields marked * are required.

Patient Details

Preferred practice location* Geelong Hoppers Crossing

Gender* Male Female Prefer not to answer Not listed

Preferred Pronoun* He She They Prefer not to answer Not listed

Patient's First Name*

Patient's Last Name*

Date of Birth*

Home Address*

Suburb*

Postcode*

Phone No (H)*

Phone No (W)*

Phone No (M)*

Email Address*

Patients School / University

If patient is a minor, please give parent(s) or Guardian’s names:

Patient lives with: Parent(s) / Mother / Father / Self /Other*

Family Dentist

Who referred you to our practice?

Do you have a Medicare?* Yes No

Medicare Number*

Reference Number*

Medicare Expiry Date (MM/YYYY)*

Are you covered for Orthodontic Treatment by private health insurance?* Yes No

If so, name of insurer

Responsible Party Information (The Person who is responsible for paying for your treatment)

The payment plans we offer are based on the information you provide below and are designed to help you.
If you do not wish to complete this section below, then we shall be very limited in the financial arrangements we can offer you.

Or, please provide details if responsible party is different to patient:

First Responsible Party Details

Responsible Party First Name

Responsible Party Last Name

Date of Birth

Relationship

Home Address

Postcode

Phone No (H)

Phone No (W)

Phone No (M)

Employer/s

Occupation/s

Second Responsible Party Details