Consent Form - School

Childsmile™ FREE Dental Program Consent Form
(School)

You can complete and sign this form online in under 5 minutes, no printing needed.
School Name*
School Suburb*
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
Phone 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 Option*

Medicare
Address
Street number and name*
Suburb*
State*
Postcode*
To deliver the services, we will conduct a Medicare Child Dental Benefits Schedule (CDBS) eligibility check. If your child is eligible, we kindly seek your consent to proceed with the following dental services: comprehensive examination, scale/clean and polish (removal of debris and stains), fluoride and fissure sealants as required. If your child is not eligible for Medicare CDBS benefits, we will provide a complimentary comprehensive examination.

All kids will be provided with a detailed report with in 2 business days after the appointment, which will be emailed to the centre/school. Please indicate your consent by signing below.
Signature*

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

DayMonthYear
Automatically selects today's 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/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):*
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.
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.
Should be Empty:

Childsmile™ FREE Dental Program Consent Form

(School)

Child's Details

Parent / Guardian's Details

Medicare Details

Address

Child's medical history