FREE Dental Service Enrolment

FREE Dental Service Enrolment

ENROL or DECLINE below:
Do you wish to ENROL your child or DECLINE our service?*

Enrol (complete section 1)Decline (complete section 2)

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 NameLast Name
Name of Child (Preferred)

First NameLast Name
Date of Birth (Child)

DayMonthYear
Date
Gender
School your child currently attends
School Year
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?

YesNo
Do you consent for your child to receive treatment for FREE by the Tooth Group as necessary?

YesNoOther
Additional Comments

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 NameLast Name
Relationship to Child

ParentGrandparentLegal GuardianSelfOther
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

SuburbPost Code

Post Code

SECTION 2: DECLINE

Please fill out the details below to DECLINE consent and for DHB reporting purposes.
Name of Child (Legal)

First NameLast Name
Date of Birth (Child)

MonthDayYear
Date
School your child currently attends
Childs current dental practice
Additional Comments

SECTION 1: ENROL