Braces N Faces :: Medical history

Patient Information Form

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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:

Emergency Information:

General Information:

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

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By clicking submit you are agreeing to our privacy policy

255 Pakington Street
Newtown
VIC 3220
Australia

(03) 5221 6677

Mon
8:00am - 5:00pm
Tue
8:00am - 5:00pm
Wed
8:00am - 5:00pm
Thu
8:00am - 5:00pm
Fri
8:00am - 5:00pm

Directions & Opening times

1 Paloma Court
Hoppers Crossing
VIC 3029
Australia

(03) 9748 9224

Mon
8:30am - 4:30pm
Tue
8:30am - 4:30pm
Wed
8:30am - 4:30pm
Thu
8:30am - 4:30pm
Fri
8:30am - 4:30pm

Directions & Opening times