Mobile Dental Care - Childcare Consent Form

Mobile Dental Care Australia is pleased to announce that it will be bringing an exciting new healthcare initiative to your child's childcare centre. A team of registered dental professionals will be onsite during centre hours to provide students with comprehensive dental examinations, education and treatment.

Parents/Guardians will receive a comprehensive report regarding their child's dental health, complete with detailed dental imaging and tailored education. The program aims to remove barriers surrounding dentistry and make excellent dental care accessible to everyone.

This program includes free, onsite treatment to eligible children with no GAP, bulk-billed under the Medicare Child Dental Benefits Schedule (CDBS), an Australian Government Program.

A significant number of children have undetected dental problems, with 1 in 3 Australian children having dental decay by the age of 5. Prevention is always better than cure. The best way to prevent oral health problems and dental infections for life is excellent oral health education from an early age. This program includes fun and interactive educational sessions, allowing children to establish great oral health habits they can take with them throughout their life.

If you are interested in this service for your child, please complete the consent form below.

If you have any questions or would like further information, contact Mobile Dental Care Australia at 1300-01-6322 or info@dentalcareaustralia.com. You can also find details about this service at www.dentalcareaustralia.com.

Child's Surname

Child's First Name(s)

Child's Date of Birth

Date

Childcare/Daycare/Preschool Name

Child's Gender

Please select all that apply and provide details if YES is selected:

	YES	NO
Allergies?
Medical conditions?
Medications?
Recent dental treatment?
Dental pain or concerns?

Provide details if YES is selected above:

Medicare Card Number

Patient Reference Number on Medicare Card

Single digit number on left side of patients name

Medicare Card Expiry Date

Parent/Guardian Name

Contact Number

Home Address

Email Address

example@example.com

Please tick all that apply:

Please conduct Medicare eligibility checkIf eligible, and recommended by the dentist, please provide FREE examination / treatment plan / clean / polish / fluoride / dental imaging / x-rays / fissure sealants / fillings under CDBS. Should a procedure such as an extraction or metal crown be necessary, we will contact the parent / guardian.If not eligible, and recommended by the dentist, please provide FREE examination / treatment plan / clean / polish / fluoride / dental imaging / x-rays.

Additional Notes (if required)

E.g. No Fillings, No X-rays, No Fluoride

We are completely transparent about what treatment is recommended and will never provide unnecessary treatment.
If you tick a box above and we find that the patient does not require the treatment selected, we will contact the parent/guardian and advise them on the best treatment option.

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT 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. 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.

Parent / Guardian Name

Date

Signature

Mobile Dental Care Australia Child Consent Form

Patient Information

Medicare Card Details

Parent/Guardian Information

Treatment Options

Declaration