Submission of this form is intended to request an
appointment at Jervis Bay Smiles. Your appointment
is not confirmed until our staff contact you using
the details provided.
Full payment is required at the time of service.
Payment can be made by cash, EFTPOS, credit card
and/or via your health insurance provider using
HICAPS.
Note, there may be out of pocket expenses for
services not entirely covered by your health fund.
Please ask our staff for further details.
Jervis Bay Smiles protects your personal
information, including that provided on this form.
Further information can be found in our
privacy policy.