Childsmile Program Parent's Consent Form

Childsmile™ Dental Program Consent Form
(School)

This form can be completed and signed online in under 5 minutes, with no printing required.
School Name*
School Suburb*
Please enter the suburb name, not the postcode.
Room/Group*
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*
example@example.com
Mobile Number*
Please enter a valid phone number.
Which days your child attends the school*

MondayTuesdayWednesdayThursdayFriday
Medicare Details
Medicare Number*
Please enter 10 digit medicare number.
Individual Reference Number*
Please enter 1 digit IRN Number
Payment Options
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.

Payment must be made by the day before we visit your child's school to avoid your child missing out. All payments are refunded in the afternoon if your child does not go ahead with the service.
Address
Street number and name*
Suburb*
State*
Please use drop down 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.
Are you 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/chickenpox) recently
Asthma/bronchitis/lung conditions
Kidney conditions
Tuberculosis
Hepatitis A, B or C
Chronic 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:*
ALLERGIES (e.g. latex, milk protein, strawberries etc):*
After your child's appointment you will receive a report within 2 business days, which will outline what treatment was completed and if anything further is required. If your child requires anything of urgent matter, you will receive a call.

By signing this form I, the parent/legal guardian certify that : I have completed the form to the best of my knowledge, I understand that failure to make a full disclosure may place my child at undue medical risk or compromise their treatment, I give The Smiles Dentacare permission to share this consent form and post care notes with my child's school/centre. I understand that by completing this form, I give The Smiles Dentacare permission to see my child for 2 visits in this calendar year.
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.
Patient's Medicare Card Number*
Patient's Name*

First NameMiddle NameLast 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

(School)

Child's Details

Parent / Guardian's Details

Medicare Details

Payment Options

Address

Child's medical history