Complete this form to request a detailed rebate estimate prior to undergoing treatment.
If you would like to receive a benefit estimate for dental treatment, please complete our separate dental estimate form.
Doctor/Specialist/Surgeon who will be providing or supervising your procedure or treatment.
Please complete all that apply (e.g. "Item no: 123" & "Charge: $100")
Please enter any other information you feel is relevant to this section
Anaesthetist (if applicable)
Please complete all that apply.
Assisting Doctor / Specialist / Surgeon who may be assisting with provision of your procedure or treatment (if applicable)
Prosthesis details (if applicable)
Your treating doctor will be able to advise you of these items if required for your procedure.