Childsmile Dental Program Consent Form - Childcare & Kindergarten

Childsmile™ Dental Program Consent Form
(Childcare & Kindergarten)

You can complete and sign this form online in under 5 minutes, no printing needed.
Centre Name*
Centre Suburb*
Child's Details

Please enter child's name exactly as shown on the medicare card
Child's Name*

First NameMiddle Name (Leave it empty if no middle name)Last Name
Date of Birth*

DayMonthYear
Enter manually or use calendar button to select the date of birth.
Child's preferred name
Parent / Guardian's Details
Parent / Guardian's Name*

First NameLast Name
Email*
Please enter the correct email address, as the report will be sent to this address.
Mobile Number*
Please enter your mobile number.
Which days your child attends the centre ?*

MondayTuesdayWednesdayThursdayFriday
Medicare Details
Medicare number*
Please enter 10 digit medicare number.
Individual Reference Number*
Please enter 1 digit IRN Number
Payment Options
Payment must be made by the day before we visit your child's centre to avoid your child missing out. All payments are refunded in the afternoon if your child does not go ahead with the service.
You must select one payment option*

Medicare - Not every children are eligible for the Medicare Child Dental Benefits Scheme (CDBS). If you are selecting this option, please ensure your child is eligible for CDBS.Send Tyro Health link to pay $69 using credit card, if not eligible for CDBS
We use Tyro health as our secure payment processing platform. For all credit card payments, you will receive an invoice, which can be used to claim back from your private health fund, if you have dental coverage.
Address
Street number and name*
Suburb*
State*
Please use dropdown list to select other states.
Postcode*
Please conduct Medicare eligibility check If eligible please provide a scale, clean and polish, fissure sealants, removal of deposits (debris and stains) and fluoride as required. If not eligible, we will contact you to discuss alternative options.

Please sign below if you consent to us providing the above-mentioned services.
Signature*

Clear
Please use your mouse or touchscreen to sign.
Date*

DayMonthYear
Automatically selects today's date. Use the calendar button to select another date.
Child's medical history

Past/Current medical conditions that are dental related or we need to be aware of when treating your child
Please provide child's details or discuss it with your dental practitioner. Information about your child's medical history is for your dental practitioner's use ONLY.
Is your child receiving any medical treatment at present?*

YesNo
Please provide the medical treatment details*
Has your child had any serious or long-standing illness?*

YesNo
Please provide the long-standing illness details.*
Has your child ever been hospitalised?*

YesNo
Please provide hospitalisation details.*

Please indicate if your child has ever had any of the following*

	Yes	No
Any heart complaint/treatment
Rheumatic fever or heart valve surgery
High or low blood pressure
Epilepsy
Diabetes
Any nervous system disorder
Blood disorders/bleeding disorders
Infectious disease (measles/chicken pox) recently
Asthma/bronchitis/lung conditions
Other

Other conditions (ADHD, Autism etc) or oral concerns not listed that will assist us in providing appropriate oral health care for your child:*
If this question is not applicable to your child, please write No or NA
ALLERGIES (e.g. latex, milk protein, strawberries etc):*
If this question is not applicable to your child, please write No or NA
I agree that the above is a true and accurate record. Please note, this form is a guide only and you should discuss any relevant matters with your dental practitioner prior to commencement of any dental treatments.
Signature*

Clear
Please use your mouse or touchscreen to sign.
Date*

DayMonthYear
Automatically selects today's date. Use the calander button to select another date.
Patient's Medicare Card Number*
Patient's Name*

First NameMiddle Name (Leave it empty if no middle name)Last Name
Full name of the person signing (if not the patient)*

First NameLast Name
Signature*

Clear
Please use your mouse or touchscreen to sign.
Date*

DayMonthYear
Automatically selects today's date. Use the calendar button to select another date.
Should be Empty:

Childsmile™ Dental Program Consent Form

(Childcare & Kindergarten)

Child's Details

Parent / Guardian's Details

Medicare Details

Payment Options

Address

Child's medical history