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SmileBack Dental Program: CashBack Claim Form
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* Indicates required question
My dental visit was less than 1 month ago
*
Yes
Amount paid for dental treatment was $200 or more
*
Yes
Patient Details
Title
*
Your answer
First Name
*
Your answer
Family Name
*
Your answer
Postcode
*
Your answer
CashBack to
*
Bank
Paypal
Bank BSB
6 numbers
Your answer
Bank Account Number
Your answer
Email
*
Once we have sent your CashBack, we will email confirmation to this address
Your answer
Email
*
Please enter your email again
Your answer
Claim Details
Date of Visit
*
DD/MM/YY
Your answer
Dentist Name
*
SmileBack Dentist
Your answer
Dentist Suburb
*
Your answer
Amount healthfund paid
*
"BENEFIT" = healthfund payment.
Your answer
Amount paid out of your own pocket
*
Cash, Credit Card, etc.
Your answer
Amount claimed through Medicare
*
Your answer
Total Amount Paid
*
Your answer
Major Dental treatment: did you have have of the following?
Please select from the list below and also circle the items on your receipt
Crown / Bridge
Denture
Root Canal
Surgical Extraction
Coupon Code
If any coupon code, please enter here
Your answer
FeedBack
How satisfied are you with the following:
Receptionist
*
Very Dissatisfied
1
2
3
4
5
6
7
8
9
10
Very Satisfied
Dental Assistant
*
Very Dissatisfied
1
2
3
4
5
6
7
8
9
10
Very Satisfied
Dentist
*
Very Dissatisfied
1
2
3
4
5
6
7
8
9
10
Very Satisfied
Treatment Received
*
Very Dissatisfied
1
2
3
4
5
6
7
8
9
10
Very Satisfied
Overall Experience
*
Very Dissatisfied
1
2
3
4
5
6
7
8
9
10
Very Satisfied
How likely are you to visit this dental surgery again?
*
1
2
3
4
5
6
7
8
9
10
How likely are you to refer a friend?
*
1
2
3
4
5
6
7
8
9
10
Other Comments
*
What does your dental surgery do well? What could it do better? ... etc
Your answer
Acknowledgements
I will be sending my receipts to help process my claim
*
Please email, fax or mail your receipts to us within 1 month of your dental visit
Yes - my receipts will arrive within 1 month of my dental visit (processing fee: 5% of CashBack)
No - I will not be sending my receipts (processing fee: 40% of Cashback)
I understand that it usually takes 1 month before I receive my CashBack
*
Medicare submissions may take longer, as your dentist has not yet received payment
No - please just accept my feedback but do not process my claim
Yes
I understand that if I make a false claim, this claim and any future claims may be void
*
No - please just accept my feedback but do not process my claim
Yes
I agree to the terms and conditions as listed in the "Details" section on the SmileBack Dental Program website
*
No - please just accept my feedback but do not process my claim
Yes
Please check claim details
Please check claim details are correct and then submit your claim.
Automation confirmation is not sent after submit button is pressed.
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