TTF Consent Form

Consent Form

You will need your Medicare card details ready
Childcare Centre & Location *
Child’s name (as on Medicare Card)*

First Name, Middle NameLast Name
Child’s Date of Birth *

DayMonthYear
Date
Parent/Guardian First Name*
Parent/Guardian Last Name
Phone number*
Mobile preferred
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
Medicare Card Number*
Child individual reference number *
Expiry date*
Upload image/screenshot of Medicare Card

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

ALL DAYSMondayTuesdayWednesdayThursdayFriday
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
Medical History

Please provide details for your child
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.*

Rheumatic FeverHeart problemsExcessive bleedingAsthmaEpilepsyPersistent cough/bronchitisDiabetesHepatitisSleep apnoeaTreatment for any form of cancerNONE OF THE ABOVEOther
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
CONSENT

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 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.

Why We Use Audio Recording
To support high-quality care, our practice may use secure audio recording with AI-assisted transcription (such as Plaud AI) during your child’s appointment. This helps clinicians accurately document discussions, clinical findings, and care recommendations, allowing us to focus more fully on your child during the consultation.

What This Involves
Only the audio of the clinical consultation is recorded
No video recording takes place
The recording is transcribed securely and reviewed by the clinician
The final clinical notes form part of your child’s health record

How Information Is Used
Recordings and transcripts are used solely for clinical documentation and continuity of care
Information is not used for training, research, marketing, or any non-clinical purpose
Audio recordings may be deleted once accurate documentation is completed, in line with our record-keeping and privacy policies

Privacy and Confidentiality
We understand the importance of protecting your child’s privacy. All recordings and transcriptions are managed in accordance with the Privacy Act 1988 (Cth) and relevant state or territory health records legislation. Access is restricted to authorised clinical staff, and reasonable safeguards are in place to protect your information. Plaud.AI is HIPAA, GDPR, SOC 2 Type II and Australian Privacy Principles (APP) compliant. The company employs robust encryption for all data transmissions and storage, ensuring that sensitive professional conversations remain protected from recording to cloud processing.

I acknowledge I am able to withdraw consent at any time. Please contact us if you do not consent or wish to withdraw consent.
Signature*

Clear
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.
Declaration

I (Parent/Guardian) acknowledge that the above information is accurate and I will advise my dentist of any changes to the above information in the future.
Full name of person signing*
Parent/Legal Guardian signature*

Clear
Date*

DayMonthYear
Date
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.
Should be Empty:

Consent Form

Medical History

CONSENT

Declaration