WA Youth Dental Services
Consent Form
Guardian's Full Name
*
First Name
Last Name
Guardian's Contact Number
*
Please enter a valid phone number.
Format: (00) 0000-0000.
Guardian's Email Address
*
example@example.com
Child's Full Name (as printed on Medicare Card)
*
First Name
Last Name
Child's Date of Birth
*
-
Day
-
Month
Year
Child's Preferred Name
Child's Medicare Number
*
10-digit number on your Medicare card
Child's Individual Reference Number
*
Single-digit number to the left of your name on Medicare card
Has Your Child Had a Dental Check-Up in The Last 6 Months
*
Yes
No
Sex
*
Male
Female
Name of Youth Accommodation/School
*
ADHD
Yes
No
Bleeding disorder
Yes
No
Lung disease
Yes
No
Diabetes
Yes
No
Infectious disease
Yes
No
Hepatitis A,B,C
Yes
No
Does your child have any conditions which are not listed above
Please list any medications your child is currently taking
Does your child have any allergies
I consent to my child receiving an examination, clean and fluoride application if required
*
Yes
No
I consent to WA Youth Dental Services checking the eligibility of my child's Medicare Child Dental Benefits Schedule status
*
Yes
No
I consent to WA Youth Dental Services sharing my child's records with other healthcare professionals for referral purposes
*
Yes
No
If WA Youth Dental Services visits my child's school/youth program twice in the same calendar year, I consent to them seeing my child without needing a new consent form; beginning from the date of the initial examination
*
Yes
No
I consent to my child attending dental appointments
*
Yes
No
Full Name of Guardian
*
By signing this document I confirm that A) All information provided is true and to the best of my knowledge B) I understand any false or misleading information may negatively impact my child C) Give permission to WA Youth Dental Services to share this form with my child's school/organisation if required D) I give permission for my child to attend dental appointments.
Sign Here
*
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