Get ready for a healthy smile!

Our school is thrilled to welcome the Dental Health Van, which will provide dental care and education to our students.

A healthy, happy smile can make a big difference to how you feel about yourself.

Good oral health means you can say goodbye to bad breath and feel confident in your daily life.

Your smile is an important part of your overall health. By prioritising it, you'll be investing in a healthy, happy you.

Funded by Australian Dental Health and the Child Dental Benefits Schedule (CDBS) - a Medicare initiative.

• CDBS-eligible students: Bulk-billed dental exams, cleaning, teeth remineralisation, preventative and restorative treatments.
• Non-eligible students: FREE Dental Health Screening and report. Students with
• Private Health Insurance: Receive comprehensive checkups, clean, and X-rays (if required) with your insurance details - no gap fees.

Please fill out and submit this form this week to enroll your child in the free dental program.

Does your child have any of the following conditions? Please tick ‘Yes’ or ‘No’ for each option.

01 Privacy and Consent

I have read and understood the privacy information on SIGN HERE page 4. I acknowledge and agree to how the program will manage student healthcare information.

02 Medicare Consent and Dental Treatment Authorisation

• I have read and understood the Medicare Bulk Billing section of this form, including the safety and benefits of the dental check-up and preventive care treatments as outlined at www.adhv.com.au/dentaltreatment. I have had an opportunity to ask questions and seek clarification on the information I have been provided by calling ADHV on 03) 9323 9607.
• I understand that I DO NOT have to pay these costs and that they will be deducted from my child's CDBS Medicare balance.
• I give consent to ADHV to provide dental treatment to my child including a Comprehensive dental examination (Item 88011 I understand if my child requires a clean (Item 88111 or 88114) and/or remineralisation (Item 88121) for their teeth, I give further consent.
• By providing Private Health Insurance details, I authorise ADHV to process claims through my private health insurer for services provided if not eligible for CDBS.
• If my child is not Medicare eligible, I understand ADHV will provide a free dental health screening and report. Please specify if you have anything to note or do not consent to a specific treatment listed above.

03 Small Dental X-rays (Item 88022)

Significantly increase the detection of tooth decay and are safe for people of all ages. I give consent to take up to 2 small dental x-rays for diagnosis if they are required.

04 Fissure Sealants are a coating/seal that help prevent cavities (Item 88161 & 88162)

I also consent to place seals on my childs teeth (molars) if they are required (up to 4 seals

I, the patient / legal guardian, certify that I have been informed:

Of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule;

Of the likely cost of this treatment; and

That I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.

I understand that I/the patient will only have access to dental benefits of up to the benefit cap.

I understand that benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule.

I understand that the cost of services will reduce the available benefit cap and that / will need to personally meet the costs of any additional services once benefits are exhausted.

 

ADHV will not charge any out of pocket costs for services completed.

This form is valid up to 31 December of the calendar year for which it is signed.