Book A Teledentistry Consultation

DATE OF BIRTH*

Please fill out the medical history form and upload your completed form.*

Preferred time to call.*

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I have read and understood the information provided above. I agree to have records, including electronic versions of X-rays, photographs, charting of conditions and health and other history information, collected from me and shared and used as described in this consent form and Privacy Policy I have received. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment I have requested and authorised.

Patient or patient’s parent/legal guardian must write their name and digitally sign below*.