Dental Estimate Request Form

Before receiving any dental treatment we recommend that you complete the form below or call us on 1300 13 40 60 for a rebate estimate so you know exactly what your gap, if any, might be.

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Complete this form to request a rebate estimate

Your full name*

Please confirm your full name as per your HIF membership card

HIF member number*

Please confirm your HIF membership number as per your HIF membership card

Your email address*

Please confirm the best email address to contact you on

Your date of birth

Your Phone Number*

Please confirm the best telephone number to contact you on

Please attach your dental estimate here

Please attach a clear scan or photograph of your itemisied dental estimate. Illegible photographs will be rejected.

Please attach any additional photographs here

Please attach a clear scan or photograph of your itemisied dental estimate. Illegible photographs will be rejected.

How would you like to be advised of your estimate?*

Email me

Phone me

Anticipated date of treatment*

Additional comments regarding your dental treatment

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Dental Estimate Request Form

Complete this form to request a rebate estimate

Data Collection