FREE Dental Service Enrolment
Do you wish to ENROL your child or DECLINE our service?
*
Enrol (complete section 1)
Decline (complete section 2)
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SECTION 1: ENROL
Please fill out the form below to ENROL your child with the Tooth Group - onsite dental service
A) Basic Information
Name of Child (Legal)
First Name
Last Name
Name of Child (Preferred)
First Name
Last Name
Date of Birth (Child)
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Non-Binary
Prefer not to say
School your child currently attends
Please Select
Al-Madinah
Alfriston College
Aorere College
Auckland Seventh Day Adventist High School
Auckland Girls Grammar School
De La Salle College
Sir Edmund Hillary
Kia Aroha College
Macleans College
McAuley High School
Mission Heights Junior College
Onewhero Area School
Ormiston Junior College
Ormiston Senior College
Pakuranga College
Pacific Advance Secondary School
Pukekohe High School
Rosehill College
Sancta Maria College
South Auckland Middle School
Tangaroa College
TKKM Mangere
Te Kura Māori o Ngā Tapuwae
Tuakau College
Wesley College
Zayed College for Girls
School Year
Please Select
Year 9
Year 10
Year 11
Year 12
Year 13
NHI (if known)
B) Consent
Do you give consent for your child to be seen by The Tooth Group for their FREE consultation (including x-rays) at school?
Yes
No
Do you consent for your child to receive treatment for FREE by the Tooth Group as necessary?
Yes
No
Other
Additional Comments
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C) Medical Information
Please disclose any medical conditions your child may have and any medications they may be taking. Write N/A if not applicable
D) Contact Information
Name of Contact
First Name
Last Name
Relationship to Child
Parent
Grandparent
Legal Guardian
Self
Other
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
Suburb
Post Code
Post Code
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SECTION 2: DECLINE
Please fill out the details below to DECLINE consent and for DHB reporting purposes.
Name of Child (Legal)
First Name
Last Name
Date of Birth (Child)
-
Month
-
Day
Year
Date
School your child currently attends
Please Select
Al-Madinah
Alfriston College
Aorere College
Auckland Seventh Day Adventist High School
Auckland Girls Grammar School
De La Salle College
Sir Edmund Hillary
Kia Aroha College
Macleans College
McAuley High School
Mission Heights Junior College
Onewhero Area School
Ormiston Junior College
Ormiston Senior College
Pakuranga College
Pacific Advance Secondary School
Pukekohe High School
Rosehill College
Sancta Maria College
South Auckland Middle School
Tangaroa College
TKKM Mangere
Tuakau College
Wesley College
Zayed College for Girls
Childs current dental practice
Additional Comments
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Full Name of Parent/Guardian Completing Form
*
First Name
Last Name
Relationship to Child
*
Parent
Grandparent
Legal Guardian
Self
Other
SUBMIT FORM
Should be Empty: