Dental Informed Consent Form

Dental Informed Consent Form
Centre Information
Centre Name*
Suburb*
Room child is in eg. infants*
MondayTuesdayWednesdayThursdayFriday
Patient Information
Patient Name (as appears on Medicare Care)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemaleOther
Medicare Card Number*
10 Digit Number
Medicare Reference Number*
Single Digit Next to Patients Name
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Emergency Contact Details
Parent/Guardian Name*

First NameLast Name
Phone Number*
Relationship*
Medical Details
Respiratory disease e.g. asthma, lung disease, TB (tuberculosis).Heart condition or heart murmur.Low or high blood pressure.Excessive bleeding or blood disorder.Seizures or epilepsy.Hepatitis A, B or CHeart surgery e.g. artificial heart valve, pacemaker.Rheumatic fever.Treatment for cancer, including chemotherapy or radiation therapy.Injury to head, neck or spine.Diabetes (type 1 or 2).Kidney Disease.None
Does your child have any allergies? This includes food, medicines, and/or products. e.g. latex, artificial flavours, milk protein (casein). *
If yes, then please specify it on the field above.
Is your child currently taking any medications?*
If yes, then please specify it on the field above.
Are there any illnesses or limitations that we should take into account when treating the patient? a physical disability, such as the need for a wheelchair, an intellectual or sensory impairment, or a mental or psychological disorder.*
If yes, then please specify it on the field above.
Dental Procedure Details
Not all children are eligible for Medicare bulk billed Child Dental Benefit Schedule (CDBS). However, we offer the same services to all children at a small fee. We are able to check the eligibility of your child with their medicare details provided above. Please select down below with options you would like.
Oral Examination and Clean - This includes exam of teeth, muscles, soft tissues, gums and bite, as well as removal of plaque and/or calculus, and apply remineralisation application to teeth if required.
Do not see child at all.Oral Examination This includes exams of teeth, muscles, soft tissues, gums and bite. $56.Oral Examination and Clean This includes removal of plaque and/or calculus, and apply a fluoride varnish to remineralise your teeth if required. $80.
YesNo
If you have private health insurance an invoice will be provided at the end of the day via email where you can claim reimbursements from your health care fund depending on your level of insurance.

An Oral Examination Report will be provided at the end of the day once your child has been seen, indicating the treatment completed, which will state the findings and possible need for further dental treatment by your local dentist or a specialist.

Once your child has been seen payments can be made via debit/credit over the phone, directly into our account, or an invoice with a secure payment portal will be SMS to you.
Any dental concerns for your child?*
If yes, then please specify it on the field above.
Acknowledgment and Waiver
I allow and authorize Toothfairy Dental Care to perform the ticked procedures on my child. The dental practitioner explained the nature of the treatment and how it will help my child.I acknowledge that all information I provided in this form is true and accurate.I acknowledge failure to make full disclosure of medical health may result my child at medical risk or compromise their treatment.I consent to allow my child to participate in Toothfairy Dental Care program and perform the selected dental services as ticked above.I acknowledge the services will be conducted at the center premises by a registered Dental Practitioner.
I consent to allow Toothfairy Dental Care to take photos of my child’s participation and to allow it for social media use.
Parent / Legal Guardian Signature*

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Signed Date*

MonthDayYear
Date

CHILD DENTAL BENEFITS SCHEDULE

BULK BILLING PATIENT CONSENT FORM

I, the patient / legal guardians, certify that I have been informed:
- of the treatment that has been or will be provided from this date under the Child Dental Benefit Schedule;
- of the likely cost of this treatment; and
- that I will be bulk billed for services under the Child Dental Benefit 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.

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.
Patient's Medicare Number*
10 Digit Number
Patient's Full Name*
Full name of person signing the form (if not the patient)*
Parent / Legal Guardian Signature*

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Signed Date*

MonthDayYear
This form is valid up to 31 December of the calendar year for which it is signed.
Should be Empty:

Dental Informed Consent Form

Centre Information

Patient Information

Parent/Guardian Information

Emergency Contact Details

Medical Details

Dental Procedure Details

Acknowledgment and Waiver