New Patient Form

To request an appointment with Dr Fracaro please complete the information below and it will be sent through to our reception staff for processing.

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Child's Details

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Nickname
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Postcode
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Postcode
Child's favourite activity / hobbies / sports / toys / pet etc...
Name of your child's childcare centre / kindy / preschool / school / high school.
(if applicable)
If there is something about your child you would like us to know which has
relevance to the dental setting, please feel free to elaborate.
(e.g. a previous experience, anxious, loud noises)

Medicare Details

Medicare Number
Medicare Reference
Medicare Expiry

Parent 1 Contact Details

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Telephone Required Field
Home Work Mobile
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Parent 2 Contact Details

Full Name
Occupation
Work Address (not postal)
Home Address
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Home Work Mobile

Other Information

Private Health Insurance
Yes No
Type of Cover:
Hospital Only Dental (extras) only Hospital and Dental
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Payment is due in full at the time of the consultation. We do not issue accounts. Please note Health Funds do not cover all fees and so the "GAP" must be paid at every visit.
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(NB. We accept EFTPOS, MasterCard, Visa, Cash & Process Health Insurance Claims On-the-Spot.)
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