Consent Form

Consent Form
Please fill out the form for us to check if your child is eligible for the Government CDBS grant. If they are eligible, they will be seen by the Dental practitioner and charge will be bulk billed to Medicare. IF YOUR CHILD IS NOT ELIGIBLE FOR CDBS PLEASE CHOOSE ONE OF THE BELOW OPTIONS*

My child is eligible for CDBS. In case my child is NOT eligible, I am happy to pay $99 out of pocket fee.My child is eligible for CDBS. IF my child is NOT Eligible, Do not see my Child .Perform Check-up and clean for my child for flat fee of $99.My child has health insurance which covers dental Extras. Perform check-up and clean for my child for flat fee of $99, send me the invoice to claim with my health insurance provider. Rebates vary between health funds.
School/Kinder /Childcare consent form
Full Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Gender*

MaleFemale
Which School/Kinder does your child attend?*
What Year/ Class/Group/Room
Kinder/ School Branch( For example - Preston South Branch)
Which days does your child attends Kinder/school?*

MondayTuesdayWednesdayThursdayFriday
Medicare Card Number*
Child Individual Reference Number*
Parent, Guardian
Parent / Guardian's Name*

First NameLast Name
Residential Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Mobile Number*
Parent/Guardian Email Address*
Emergency contact details.
Parent / Guardian's Name*

First NameLast Name
Relationship*
Contact Number*
Medical Practitioner Details
Practice Name
Doctor
Phone
Address
Medical History
Please tick if your child has or had any of the following medical conditions. If yes, Please provide further information:

DiabetesHeart conditionsBleeding DisorderHigh/Low blood pressureArtificial heart valveAsthma/Breathing difficultiesADHDAutismKidney conditionsInfectious diseasesHepatitis A,B or CTuberculosisEpilepsyChronic conditionsOther
Other or further information
Does your Child have any Allergies?*

YESNO
If Yes, please provide additional information below*

YESNO
If Yes, please provide additional information below and mention if your child uses an inhaler or requires an EpiPen.
Has your child had any operations?*

YESNO
If Yes, please list the operations and their dates below
Dental History
Are there any main dental concerns for your child?*

YESNO
If Yes, please provide additional information below
Has your child visited the dentist in the last 6 months?*

YESNO
If Yes, please provide details below
Treatments
- Dental check-ups: A comprehensive oral and extra oral examination will be done by our dentist who has experience working with children. This includes tracking your child’s dental development clinically and with the help of x-rays when needed. This enables us to institute preventative measures (e.g., fissure sealants to prevent decay when your child is at high risk for decay) and undertake treatment when required (e.g., filling a decayed tooth). Treatment is only done if a need for it has been established based on your child’s specific treatment plan. After the check-up, should your child require urgent treatment, or is best seen by a specialist, you will receive a call or an e-mail from us. Every child will also be given a report of their visit to take home to their parents.A comprehensive oral and extra oral examination will be done by our dentist who has experience working with children. This includes tracking your child’s dental development clinically and with the help of x-rays when needed. This enables us to institute preventative measures (e.g., fissure sealants to prevent decay when your child is at high risk for decay) and undertake treatment when required (e.g., filling a decayed tooth). Treatment is only done if a need for it has been established based on your child’s specific treatment plan. After the check-up, should your child require urgent treatment, or is best seen by a specialist, you will receive a call or an e-mail from us. Every child will also be given a report of their visit to take home to their parents.
- X-rays: Small X-rays are sometimes taken at your child’s regular dental visits to check for decay and disease between teeth and also enable us to confirm the presence or absence of their adult teeth. X-rays are only done when needed for screening or treatment and are a quick and comfortable procedure.
- Fissure seals: This is a preventative procedure to clean and seal the deep grooves in your child’s back teeth which are more prone to dental decay. Research has shown fissure seals to significantly reduce chances of decay. Fast and easy with no drilling required. These have no known side effects but may need replacing from time to time.
- Fillings: A filling is done in a tooth that has decay. Decay is not always obvious which is why a set of trained eyes and x-rays help in diagnosing decay. It is cleaned out and a tooth-coloured filling placed into prevent the decay causing harm to the dental nerve. This prevents pain and infection in the future. Fast and easy procedure. And if required, numbing can be provided.
- Extractions: Loose or broken-down baby teeth can be removed painlessly at your child’s dental visit by our experienced dentist. After care instructions will be provided and should you wish to be present during the procedure, a suitable time will be arranged close to pick up time for you to be present.
I parent/guardian give consent to Dentist2You to see my child and do the below as needed.*
Comprehensive oral examination/Dental check-upX-raysScale and clean/prophy polishingFluoride gel applicationFissure sealsFillingsextractionsCrown
Declarations
By signing this form:
- I have completed the questionnaire to the best of my knowledge
- I understand that failure to make a full disclosure may place my child at undue medical risk or compromise their treatment
- I, the undersigned confirm that I am the “Parent/Guardian” of the above named Child, and have read through and understood of the treatments provided by Dentist2You, and give voluntary consent for Dentist2You, to conduct the treatments if deemed appropriate by a registered dental practitioner without myself being present on site but a STAFF MEMBER OF THE FACILITY TO BE PRESENT
Parent / Guardian's Signature*

Clear
Parent / Guardian Name*

First NameLast Name
Date*

DayMonthYear
Date
Child Dental Benefits ScheduleBulk Billing Patient Consent Form
I, the patient / legal guardian, certify that I have been informed:
- of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule;
- of the likely cost of this treatment; and
- that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.
Declaration
- I understand that I/the patient will only have access to dental benefits of up to the benefit cap.
- I understand that benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule.
- I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.
Child's Full Name*

First NameMiddle NameLast Name
Parent / Guardian's Signature*

Clear
Medicare Card Number*
Full name of person signing (if not patient)*

First NameLast Name
Date*

DayMonthYear
Date
Should be Empty:

Consent Form

Parent, Guardian

Emergency contact details.

Medical Practitioner Details

Medical History

Dental History

Treatments

Declarations

Child Dental Benefits ScheduleBulk Billing Patient Consent Form

Declaration