TTF Consent Form

Childcare Centre & Location if applicable*

Child’s name (as on Medicare Card)*

First Name, Middle NameLast Name

Child’s preferred name (if not the same as above)

Sex at birth

MaleFemaleOther

Child’s Date of Birth *

Date

Parent/Guardian First Name*

Parent/Guardian Last Name

Phone number*

Mobile preferred

Parent/Guardian First Name*

First Name

Contact preference*

Phone callText messageEmail

Email (required for dental report)*

example@example.com

The dental report will be sent by the end of the week your child is being seen. If you do not receive it, please email us to let us know as it can sometimes go into your junk mail folder.*

Please tick to acknowledge

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please tick any that apply*

Please conduct Centrelink eligibility check (to utilise CDBS - bulk billed) Up to $1026 (2022-2023) and $1052 (2023-2024)PRIVATE HEALTH: I am not eligible OR if not eligible after check, I would like a tax invoice to claim through my private health fundSELF-FUND: I am not eligible OR if not eligible after check, I would like to take up the $75 fee for services listed below

Dental Benefits Schedule 2022 Rates as set by Services Australia

Item no	Item name	Fee for service
88011	Comprehensive oral examination	$54.05
88012	Periodic oral examination	$44.90
88013	Limited oral examination	$28.20
88111	Removal of plaque and/or stain	$55.20
88121	Topical application of remineralisation and/or cariostatic agents, one treatment	$35.45

I consent to these treatments being provided to my child*

Dental examination onlyDental cleanCalcium applicationAll of the above

Medicare Card Number*

Child individual reference number *

Expiry date*

Upload image/screenshot of Medicare Card

Private Health Fund Name

eg BUPA, HCF, AHM, NIB etc

Member number

Child’s reference on card

Card issue number

For AHM, NIB, Police Health

Please tick days your child attends. We will contact you for an appointment if they do not attend on the day of our visit.*

Would you like to attend with your child? This is not necessary as some children do better without their parents present, however if you would like to be present please indicate below!*

Yes - please contact me to arrangeMaybe - please contact meNo, not necessary

It is important for us to know details about your child’s medical history as these could affect the success of your child’s dental treatment. The information you provide is confidential and will be handled in accordance with the Australian Dental Association privacy policy. It is important that you fill out the form accurately as this can adversely affect your child’s dental treatment outcomes.

Do you consent for our use of photographs taken by the centre of your child’s dental treatment for social media purposes for The Travelling Tooth Fairy?

YesNo

Is your child receiving any medical treatment at present*

NoYes

If yes, please list. *

Is your child currently taking any medication?*

YesNo

If yes, please list. If no, please write “none”.*

Please tick if your child has EVER had any of the following conditions. Please tick NONE if otherwise.*

Does your child have any other conditions? (eg Down Syndrome, ADHD, Autism, Developmental or Behavioural issues)*

YesNo

If yes, please specify

eg Down Syndrome, ADHD, Autism, Developmental or Behavioural issues

Does your child have any allergies? (eg Latex, milk protein, benzoate preservatives, soybean derivatives )*

YesNo

If yes, please list. If no, please write “none”.*

Does your child snack between meals*

Yes, less than 3 timesYes, more than 3 timesNo

How many times a day does your child brush?*

012More than 2

Have you noticed your child grinding their teeth?*

YesNoSometimes

Have you noticed your child snoring?*

YesNoSometimes

Has your child had their tonsils out?*

NoYes - tonsilsYes - tonsils and adenoidsPlease specify here

Does your child suck a dummy, thumb/finger or comforter?*

YesNoSometimesIn the past

If they have stopped, how long ago?

E.g. 1 week, 1 month, 1 year

If you have any specific concerns, or anything you’d like for our dentist to comment on in the report, please note down below:*

I confirm that above information I have provided is true, complete and accurate.*

Please tick to acknowledge

By signing this form, I acknowledge I give consent for a dental check and clean and remineralisation treatment to be carried out as appropriate. I consent to clinical photographs of my child's teeth and/or mouth to be taken where deemed necessary for assessment and treatment planning purposes. I acknowledge I am able to withdraw consent at any time. Please contact us if you do not consent or wish to withdraw consent.

I understand that radiographs (x-rays) will not be taken at the daycare/early learning centre and, where required, I will need to take my child to a dental clinic.

I understand that it is the childcare centre’s responsibility to correctly identify my child for the servicing dental practitioner.

Signature*

This form is required so that we can check your eligibility and to see your child under the bulk billed Child Dental Benefits Scheme. If they are eligible, we will see them on the day. If they are not eligible, we will call you.

The item codes that can be billed for your child and the following are the possible services we will claim (please note we will not claim all of these services, only what is applicable to your child and what we complete on the day):
88011 - Comprehensive oral examination - $59.60

88012 - Periodic oral examination - $49.55

88013 - Oral examination – limited - $31.10

88111 - Removal of plaque and/or stain - $60.90

88114 - Removal of calculus – first visit - $101.55

88121 - Topical application of remineralisation and/or cariostatic agents, one treatment - $39.15

*All benefit prices are current as of Jan 2nd, 2025.

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM

I, the patient /parent / 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

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.

Full name of person signing*

Parent/Legal Guardian signature*

Date*

Date

By filling in the form below, I consent for clinical photographs of my child's teeth and mouth where deemed necessary for assessment purposes. These photographs will be de-identified.

Iparent/guardian name consent to clinical photographs of my child's teeth/mouth as deemed necessary for assessment and treatment planning purposes. I acknowledge that these photographs will be attached in the dental report and will be stored electronically blank fields and text.

Consent Form

Medical History

Declaration

Clinical Photograph Consent