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.

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

Please use calendar, adjust year by clicking year than scroll to desired option

*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.

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


If Yes to question please provide details otherwise leave blank

If Yes to question please provide details otherwise leave blank

If Yes to question please provide details otherwise leave blank

YesNo
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

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.

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