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.

Terms and conditions: *

I would like to commit support to and active involvement in the ASO’s Give a Smile™ programme. I agree to treat my Give a Smile™ patient/s with the same high levels of care and professionalism that I offer to my full fee-paying patients, however free of charge. I understand that I am expected to start one GAS patient each year and they can be from the dental health waiting list or self screened. If I wish to start more or less than one patient a year from the public waiting list I will contact my state liaison officer to organise.

First Name: *

Surname: *

Practice Address: *

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

Phone: *

Enter your best daytime contact number or numbers

Email: *

Enter your email address