GAS Registration Form

Please complete the form below to register to become a Give a Smile Orthodontist. 

If you would like any clarification on your responsibilities, patient allocation and frequency as a Give a Smile™ orthodontist please do not hesitate to contact your State liaison officer or Give a Smile™ directly (on 1300 661 613 or email [email protected]) prior to completing this registration form. 

Provide the address of the practice/s where you are happy to treat Give a Smile™ patients

Enter your best daytime contact number or numbers

Enter your email address