Free Dental Assesment

Personal Information

First Name *

Last Name *

Date of Birth *

Nationality *

Height (Cms) *

Weight (Kgs) *

Your Contact Information

Personal Details

Home Address *

Suburb/City *

State / Province / Region *

Postal Code / ZIP *

Country *

Phone Number *

Emergency Contact (Not travelling with you)

First Name *

Last Name *

Phone Number *

Email Address (optional)

Relationship (e.g. mother, father etc) *

Destination & Treatment

Your Financial Support

Preferred Destination

Travel Information (Leave blank if you are unsure.)

Preferred Departure Airport

Preferred Departure Date

Travelling companion

First Name

Last Name

Phone Number

Email address (Optional)

Comments / Questions (if any)

Dental History

Upload Required Photos

PHOTOS ARE REQUIRED

To secure a dental recommendation from a dentist, Please make sure you have upload the correct images to match each of the pictures below:

1. Full Frontal Smile

2. Full Frontal Pulling Lips Away

3. Inside Bottom Jaw Pulling Away Lips

4. Inside Top Jaw Pulling Lips Away

5. Side Profile Left with natural bite pulling lips away

6. Side Profile Right with natural bite pulling lips away

7. An OPG Xray / CT Scan if you required one of these

Any questions for AMT?

IMAGE LOADING: If you are having problems uploading your images onto this form, submit the form and email images separately to: info@medicaltravel.com.au
Only png, jpg, jpeg files can be uploaded

Please Enter your Email address for our Confirmation email

Dental Online Assessment Form

Personal Information

Your Contact Information

Personal Details

Emergency Contact (Not travelling with you)

Destination & Treatment

Travel Information (Leave blank if you are unsure.)

Dental History

Upload Required Photos

PHOTOS ARE REQUIRED

IMAGE LOADING: If you are having problems uploading your images onto this form, submit the form and email images separately to: info@medicaltravel.com.au
Only png, jpg, jpeg files can be uploaded

Pin It on Pinterest

Dental Online Assessment Form

Personal Information

Your Contact Information

Personal Details

Emergency Contact (Not travelling with you)

Destination & Treatment

Travel Information (Leave blank if you are unsure.)

Dental History

Upload Required Photos

PHOTOS ARE REQUIRED

IMAGE LOADING: If you are having problems uploading your images onto this form, submit the form and email images separately to: info@medicaltravel.com.au Only png, jpg, jpeg files can be uploaded

Pin It on Pinterest

IMAGE LOADING: If you are having problems uploading your images onto this form, submit the form and email images separately to: info@medicaltravel.com.au
Only png, jpg, jpeg files can be uploaded