Book an Appointment

Patient Information

Please enter your child’s information below as a reference for us.

First Name*

Last Name*

Preferred First Name

First Visit to Bright Smiles?*

Date of Birth*

Gender*

Parent/Guardian contact information for correspondence.

Parent(s)/Guardian(s)*

Address

Phone (Home)*

Phone (Work)*

Phone (Mobile)*

Phone (Other)

Email*

Preferred Contact*

Phone

Text

Type of Appointment*

A checkup is part of your regular dental care that normally happens annually or six monthly.

A consultation is because you’ve been seen by someone else and referred or there’s a particular issue that you’d like looked at.

If neither of the above are quite right, select ‘Other’ and let us know what you need in the ‘Other Info’ field.

Let us know what you need

Have you been referred or are you referring yourself?*

We are more than happy to see you without a referral, but we'll get a bit of detail off you soon.

Who have you been referred by?*

Clinic

Referral Number

What is the reason for the consultation?*

Who would you like to see?*

What times suit you?*

8:30 - 10:00am

10:00am - 12:30pm

1:30 - 3:00pm

3:00 - 5:00pm