Thank you for starting the application form for Smile Koomba.
Before you take the time to fill out this form, please read the information below.

● All applications are important to us and we understand that every case is unique and urgent. However, due to the large number of applications we receive we must prioritise each application according to a points-based system, depending on the eligibility criteria outlined and the supported documents provided.
● Please ensure you have read the ‘Who We Help’ section on our website and understand the eligibility criteria you can include to strengthen your application.
● Please have relevant supporting documents ready to attach to your application.

Patient Information:

Full Name: Date of Birth: Address: Contact Number: Email Address:

Treatment Information:

Is this urgent?
[Disclaimer]: We understand that all cases are urgent, but please provide a detailed description of the urgency of your situation.

Treatment Area – Denture Required: —Please choose an option—Upper onlyLower onlyBoth
Please note: Smile Koomba is currently unable to provide partial dentures

I have had all my teeth and roots removed and am ready for denture restoration:

I have an x-ray to show:
YesNo

I am able to attend appointments in Subiaco:
YesNo

Are you currently on a government waitlist to receive dental treatment?
YesNo

Eligibility:

Please ensure you have read the ‘Who we help’ section on our website, before choosing the relevant eligibility criteria that apply to your case.
Low socioeconomic circumstancesReferral from GP or Case ManagerAboriginal and/or Torres Strait Islander communityMental illnessDisabilityCarer of person/people with disabilitiesRural or remote locationCulturally or linguistically diverse

Supporting Documents:

Please provide the corresponding supporting documents for the eligibility criteria you have selected. The list of supporting documents can be found under the 'Who We Help' section on our website. If you have more than 3 supporting documents, please email the additional documents to info@smiliekoomba.com.au.

Dental Records: