SLEEP DENTISTRY QUESTIONNAIRE
PLEASE CHECK REASON FOR SLEEP DENTISTRY CONSULT
*
Dental phobia / needle phobia
Special Needs
Uncooperative children
Wisdom teeth / orthodontic extractions
Severe Gag Issues
Other
INTERESTED IN SLEEPING THROUGH THE FOLLOWING (CHECK ALL APPLICABLE)
*
Fixing teeth / fillings / root canals / crowns
Replacing Teeth / bridges / implants / dentures
Smile Makeover / ceramic veneers / whitening
Wisdom teeth removal / extractions for braces / supernumerary teeth removal
Gum treatment
All on 4
Full / partial clearance
Other
Private Health Fund (hospital cover)
*
Yes
No
Private Health Fund (extras cover)
*
Yes
No
Medicare
*
Yes
No
Dva
*
Yes
No
Payment Options
*
Upfront payment with 10% discount
Interest free payment plan
Early Super Release
Work Cover
Other
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Anything else?
Submit
Should be Empty: