MARTIN VALE DENTISTRY

Dear Parent / Guardian,

The Martin Vale Dentistry's mobile van will be conducting dental visits to your school/preschool/kinder. Treatment may be BULK BILLED through Medicare Child Dental Benefits Schedule (CDBS) for eligible students. Students that are not eligible for CDBS funding have the option to receive treatment as a private patient.

The following explains the steps involved.

Our First Visit Students Eligible for CDBS receive an examination, X-rays, fluoride & fissure sealants Parents contacted by phone soon after to discuss a treatment plan using the available CDBS funding.

return to your school/preschool/kinder to go ahead with the treatment plan we have discussed with you and gained your consent for.

Students not eligible receive dental screening Parents contacted by phone soon after to discuss if a private appointment is recommended.

Parents are welcome to attend the dental van while their child has their treatment.

a) Our dental van is fully quipped to do fillings, fissure sealants, scaling and cleaning, extractions and fluoride application. b) If you prefer, you also have to option to have your child's treatment done at our private practice at 116 Queen Street, Bendigo.

Please complete the consent form over page if you would like your child/children to participate.

www.martinvaledentistry.com.au

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 $1,095 CDBS for ages 2-17 years old.

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