School Visits - Dental Van - Medicare Bulk Bill Consent

Please complete all the questions below, click submit at the end and we will email you a copy for your records.

Child's Full Name*

Child's DOB*

Date

Name of School*

Grade/Class*

Address*

Concerns with your child's teeth?*

List any Allergies that your child has. (if none, please write "none")*

List any Current Medications your child is taking. (if none, please write "none")*

List any other Medical Conditions that you child has. (if none, please write "none")*

Medicare Card Number*

Enter your 10 digit medicare card number

IRN NO*

Enter your child's position on Medicare Card)

Medicare Card Expiry*

M M Y Y

If your child is NOT Eligible for CDBS, please choose below:*

Pay for a $99 Dental Van Special. (Includes: Exam, X-rays and a dental clean)Receive a Complementary dental screening only.

Dental Services: (tick circle below)*

$99 Dental Van Special

$99.00AUD Quantity

Total

$0.00AUD

Credit Card

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT 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.

I understand that I/the patient will only have access to dental benefits of up to the benefit cap; / understand that benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. / understand / will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule. / understand that the cost of services will reduce the available benefit cap and that / will need to personally meet the costs of any additional services once benefits are exhausted.

I, Parent / Guardian, give consent for Martin Vale Dentistry to undertake a dental check-up, fluoride, fissure sealants and X-rays if required and I am happy for my child's dental records to be safely read and kept by Martin Vale Dentistry staff for administration purposes.

I have read and understand the steps outlined and the CDBS BULK BILLING process. I agree to the costs being BULK BILLED from my $1,132 CDBS for ages 2-17 years old.

Full Name of person signing (if not the patient)*

Patient/Legal Guardian Signature*

Date*

Today's Date

Parent/Legal Guardian Mobile*

Email *

Parent's or Guardian's email address

This form is valid up to 31 December of the calendar year which it is signed.

116 Queen St, Bendigo VIC 3550 Phone: (03) 5443 5006

Email: info@martinvaledentistry.com.au