Let’s Begin.
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 please take a look at our Photo Guide.

In completing this form, you’re also letting us know that you’ve read and understand CosMediSmile’s Terms & Conditions and Cancellation Policy. If you have any questions, we’re here to help on 1300 000 633.

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How to Take Your Photos.

Porcelain Veneers

Zirconia Crowns

Your Free Assessment.

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Step 1 of 4 - Personal Information

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

YOUR DENTAL INFORMATION

PLEASE NOTE: In order to offer you an accurate cosmetic dental recommendation, it’s important that you provide accurate dental and medical health information on this form. No matter how small or insignificant something may seem, it’s vital that you state all conditions, and include any underlying issues you may have. Please be sure to state all of your conditions and medications (both prescription and non-prescription) and to be open and honest throughout. Omitting information will result in your Dentist declining or postponing your treatment either at initial assessment or at the time of your first in-chair consultation. If you are unsure about anything, please connect with our Client Support Specialists on 1300 000 633.

Do you have gingivitis?*

Yes

Please give further details*

Do you have dental decay?*

Yes

Please give further details*

Do you grind/clench your teeth?*

Yes

Do you smoke regularly?*

Yes

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

YOUR MEDICAL HISTORY

Do you have any of the following medical conditions?

Hidden

Are you currently breastfeeding?

Yes

Heart Conditions*

Yes

Please give further details*

High Blood Pressure*

Yes

Please give further details*

Bleeding Disorder*

Yes

Please give further details*

Sinus Problems*

Yes

Please give further details*

Diabetes*

Yes

Please give further details*

Hepatitis*

Yes

Please give further details*

HIV / AIDS*

Yes

Please give further details*

Epilepsy*

Yes

Please give further details*

Mental Illness*

Yes

Please give further details*

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

Yes

Please give further details*

Please list any prescription and non-prescription medications you are taking including the dose

Have you ever used Intravenous Drugs or received Opioid Replacement Therapy?*

Yes

Do your teeth or gums have damage from recreational drug use?*

Yes

UPLOAD YOUR PHOTOGRAPHS

PHOTOS ARE REQUIRED to obtain your cosmetic dental recommendation. Please ensure you have read the example photo guide and have the following ready to upload:

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

Image Uploader*

Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 100 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

TikTok

Competition

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)

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

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 Understand CosMediSmile's Terms & Conditions, Cancellation Policy and Privacy Policy
Truthfully completed this form without any purposeful omissions
Consent for CosMediSmile to share my personal information with their Dental partners for the purpose of assessment and treatment*

Let’s Begin.Your Free Assessment.

How to Take Your Photos.

Porcelain Veneers

Zirconia Crowns

Your Free Assessment.

YOUR PERSONAL INFORMATION

YOUR DENTAL INFORMATION

YOUR MEDICAL HISTORY

UPLOAD YOUR PHOTOGRAPHS

Client Consent & Declaration

Let’s Begin.
Your Free Assessment.