• Personal Information
  • Emergency Contact
  • Destination & Treatment
  • Dental Condition
  • Upload Required Photos

Personal Information

Emergency Contact

Contact Information

Emergency Contact (Not travelling with you)

Destination & Treatment

Clinic & Travel Information

Dental Condition

Upload Required Photos

Photographs Required
PHOTOS ARE REQUIRED to secure a dental recommendation from a dentist. Make sure you have looked at the correct example photographs and upload accordingly. Please ensure you have:
  • 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
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

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