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Player’s Date of Birth:
Are you a previous patient of Whitesmile Dental Care?
DENTAL/MEDICAL HISTORY

PAYMENT DETAILS

Private Health Insurance
Please select your payment option from the following

Payment Details

Cost for players with no Health Fund $108
Players with Health Fund no out of pocket cost: item numbers billed 013 151.
In the event that your Health Fund does not cover the $108 players will need to pay the difference.

Date