Consent Form

School/Centre Name

Please put full name of centre as we do multiple centres with similar names

School/Centre Suburb

Name of child

Exactly as written on medicare card

Date of Birth

Please use calendar adjust year by clicking year than scrolling to desired option

Child's Preferred Name

If different from medicare card

Parent Guardian Name

Parent/Guardian contact number

Email

Needed to email you your childs dental report and invoice

Which days does your child attend child care

Monday

Tuesday

Wednesday

Thursday

Friday

So we know your child attends the day or we contact you for an appointment

MEDICARE DETAILS

Medicare Card Number

0 / 10

Please conduct Medicare eligibility check

Medicare Child Individual Reference Number

PRIVATE HEALTH- NO GAP DENTAL. IF NOT ELIGIBLE FOR MEDICARE

We use Medipass which is reasonably new and not all health funds have joined yet. Members of the following private Health Insurers are currently able to use Medipass to process claims: Medibank, Bupa, NIB, AAMI, Apia, AHM, Suncorp, St Luke’s Health, Frank, GMHBA, GU Health, Qantas, Healthcare Insurance (HCI), Police Health, Emergency Services Health & Nurses midwives health.

Medipass are in the process of adding new health funds so if yours isn’t supported yet, it may be next time we visit. In the meanwhile, we can send you a Medipass link for the $69 capped rate for the services and send you an invoice after the visit that you can use to claim back directly through your private health fund.

We process the claim at the full rate of the services and then discount the GAP making it NO GAP Dental.

Please ensure your child is covered for dental or you will be charged $69.

Private Health Fund Name

Private Health Member Number

Private Health Child Rank Number

Private Health Card Issue Number. E.g 01

0 / 2

FOUND ON BACK OF CARD (How many cards you have had issued)

CREDIT CARD DETAILS. IF NOT ELIGIBLE FOR MEDICARE AND DO NOT HAVE DENTAL COVER PRIVATE HEALTH FOR YOUR CHILD

Credit Card name

If not eligible please charge my card $69

Credit Card Number

Credit Card Expiry

Credit Card CVV

Pay via MEDIPASS LINK

Please send me medipass link for $69 if not eligible for medicare

My private health fund can't be claimed through Medipass. Please send me a link for $69

Other:

Payment must be made by the day before we visit your childs centre to avoid your child missing out. All payments are refunded in the afternoon if your child does not go ahead with the service.

Home Address

*Please conduct Medicare eligibility check
If eligible please provide a scale, clean and polish, fissure sealants, removal of deposits (debris and stains) and fluoride as required.

*If not eligible, we will contact you to discuss alternative options.

*Please sign below if you consent to us providing the above-mentioned services.

I am the Parent/Guardian ----------Signature

Clear

Date

Childs Medical History Questionnaire

Please provide child’s details or discuss them with your dentist.

Information about your child’s medical history is for your dentist’s use ONLY.

Past/Current medical conditions that are dental related or we need to be aware of when treating your child

Are you receiving any medical treatment at present?

Yes

No

Details

If Yes to question please provide details otherwise leave blank

Have you had any serious or long-standing illness?

Yes

No

Details

If Yes to question please provide details otherwise leave blank

Have you ever been hospitalised?

Yes

No

Details

If Yes to question please provide details otherwise leave blank

Please indicate if your child has ever had any of the following:

	Yes	No
Any heart complaint/treatment
Rheumatic fever or heart valve surgery
High or low blood pressure
Blood disorders/bleeding disorders
Epilepsy
Diabetes
Familial diseases
Infectious disease (measles/chicken pox) recently
Any nervous system disorder
Asthma/bronchitis/lung conditions
Radiation therapy/chemotherapy
Thyroid disease
Hepatitis, jaundice or liver disease
Treatment for any form of cancer
Transplanted organ or bone marrow
Kidney conditions
Tuberculosis
Other

Other conditions (ADHD, Autism etc) or oral concerns not listed that will assist us in providing appropriate oral health care for your child:

ALLERGIES (e.g. latex, milk protein, strawberries etc):

If no allergies, please write NO

I agree that the above is a true and accurate record.

Please note, this form is a guide only and you should discuss any relevant matters with your dentist prior to commencement of any dental treatments.

Signature

Clear

Date

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM

Patients Medicare number

Name of Person Signing

Patients Name

Signature

Clear

Date

Consent FormFor treatment provided by Dental2You Please fill in your childs details the best you can and submit the form below alternatively you may download this consent form and hand it in to your school office directly.

Childs Medical History Questionnaire

Past/Current medical conditions that are dental related or we need to be aware of when treating your child

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM