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.