Vital Dental Care Medical History Form

CONTACT DETAILS

FIRST NAME:*

LAST NAME:*

D.O.B:*

ADDRESS:

SUBURB:

POSTCODE:

PHONE:*

EMAIL:*

HOW DID YOU FIND US?*

GOOGLEFACEBOOKINSTAGRAMFRIENDS - PLEASE WRITE THEIR NAME

(YOU WILL BOTH RECEIVE A CREDIT AS PART OF OUR REFERRAL REWARDS PROGRAM)

PREFERRED METHOD OF CONTACT FROM US?

PHONE CALLSMS TEXT MESSAGEEMAIL

WE OCCASIONALLY EMAIL SPECIALS AND EXCITING NEWS! PLEASE TICK THIS IF YOU DO NOT WISH TO RECEIVE.

PLEASE LET US KNOW WHAT YOU WOULD LIKE TO WATCH ON NETFLIX:

PAYMENT DETAILS

WHICH HEALTH FUND ARE YOU WITH?*

WE OFFER ON THE SPOT HICAPS CLAIMS. ALL ACCOUNTS ARE TO BE PAID AT COMPLETION OF THE APPOINTMENT. WE DO NOT OFFER ACCOUNTS. WE ACCEPT CASH, EFTPOS, VISA, MASTERCARD AND AMERICAN EXPRESS.

WELCOME TO VITAL DENTAL CARE

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