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Your Free Assessment.

Start your journey by submitting this form to receive your free personalised quote. You’ll need great quality photos to upload in your form, so before you start take a look at our how to photo guide and have your photos ready. If you have any questions, we’re here to help on 1300 000 633.

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Free Assessment CosMediSmile

How to Take Your Photos.

8 Porcelain Veneers Gold Coast

Porcelain Veneers

10 Porcelain Veneers Gold Coast

Zirconia Crowns

16 Porcelain Veneers Gold Coast

Invisalign

Your Free Dental Assessment.
Please Enter Your Details.

Step 1 of 4 - Personal Information

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YOUR PERSONAL INFORMATION

Name (as it appears in your passport)*

First Last

Email Address*

Mobile Phone*

Address*

Street Address City State Postcode Country

Date of Birth*

Day

Month

Year

Gender*

Occupation*

Select Procedures*

8 Veneer Package

10 Veneer Package

16 Veneer Package

8 Crown Package

10 Crown Package

20 Crown Package

8 Gold Crown Package

10 Gold Crown Package

8 VVS Crown Package (diamond)

Invisalign

Other

Preferred Treatment Date*

DD slash MM slash YYYY

Describe the look and the results you expect:*

Do you require finance for your treatment?**

Yes

No

YOUR DENTAL INFORMATION

Do you have gingivitis?*

Yes

No

Please give further details*

Do you have dental decay?*

Yes

No

Please give further details*

Do you grind/clench your teeth?*

Yes

No

Do you smoke regularly?*

Yes

No

How many per day, and how many years?*

When was your last dental visit, and did you have a clean and scale?*

Have you discussed cosmetic dental options with your dentist? If yes, what advice did they provide you?

Have you had an OPG, CT Scan or bite wing Xrays in the last 12 months?*

Yes

No

YOUR MEDICAL HISTORY

Please Note: Providing accurate medical and dental information is important. Please ensure that you state all conditions. Your Dentist may request further information before a final evaluation is provided. Omitting information could result in your Dentist declining treatment at the time of your face-to-face consultation.

Please list your current medications and dosages

Do you have any of the following medical conditions?

Are you currently breastfeeding?*

Yes

No

Heart Conditions*

Yes

No

Please give further details*

High Blood Pressure*

Yes

No

Please give further details*

Bleeding Disorder*

Yes

No

Please give further details*

Sinus Problems*

Yes

No

Please give further details*

Diabetes*

Yes

No

Please give further details*

Hepatitis*

Yes

No

Please give further details*

HIV / AIDS*

Yes

No

Please give further details*

Epilepsy*

Yes

No

Please give further details*

Mental Illness*

Yes

No

Please give further details*

Do you have any allergies (such as Latex or Penicillin)?*

Yes

No

Please give further details*

UPLOAD YOUR PHOTOGRAPHS

PHOTOS ARE REQUIRED to obtain 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 Uploader

Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 10 MB, Max. files: 20.

Do you have any questions?

How did you hear about us?*

Google Search

Word of Mouth

Instagram Account

Instagram ''Advertisement"

Facebook Account

Facebook ''Advertisement"

Online Forum

Email

YouTube

Walk In

Newspaper or Magazine

Television

Other

We love to share before & after photos on our digital channels to help other clients. Would you be ok for us to share yours?

Yes, you can share my images

Yes, but I want to remain anonymous, so only feature my smile (we will not show your full face)

No

We love to share photos from our clients' Instagram accounts. Would you be ok for us to share your Instagram photos?

Yes, you can share my images, and you can tag me

Yes, you can share my images, but please do not tag me

No

Great, what is your Instagram @handle?

Client Consent & Declaration

Please carefully review our Terms & Conditions.
Please be aware that false declarations in relation to your medical or dental history may result in the Dentist declining or postponing treatment.
In line with our Privacy Policy, your personal information is confidential and will not be released to any other party, individual or organisation without your consent.

I declare that

I have read and agree to CosMediSmile's Terms & Conditions,
I have truthfully completed this form without any purposeful omissions,
I consent for CosMediSmile to share my personal information with their Dental partners for the purpose of assessment and treatment*

Accept

Let’s Get Started

We’re Here To Help On 1300 000 633

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All treatments carry risks & benefits. Before proceeding, we encourage you to seek a second opinion from a qualified health practitioner.

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