ADHNSW Consent Form

Get ready for a healthy smile!

Our school is thrilled to welcome the Dental Health Clinic, providing 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 return this form to school this week to enroll your child in the free dental program.

Paper Form vs. Online Form – Which One Do You Need?
Already filled out the paper form and sent it back with your child? Great! No need to do this one.

But if you're worried that the paper form might be crumpled at the bottom of their bag (next to an old sandwich), we recommend filling out the online form instead—just to be safe!

My Child's Medical History & Consent
Name

Students First NameStudents Middle NameStudents Last Name
Date of Birth*

DayMonthYear
Date
Gender

MaleFemaleOther
School Name
Year Level*
Form Group/Room*
Campus
Parent/ Guardians Name
Relationship to the student
Address
Email Address
example@example.com - Your childs oral health report may be sent via email. Please ensure the email address is entered fully and correctly.
Contact Number

Please tick Yes/No to the following:*

	YES	NO
Heart Murmur/Problem
Epilepsy
Asthma
Diabetes
Bleeding Problem
Finger/Thumb Sucking
Fainting
Anaphylaxis
Autism
Jaw or sleeping problem
Dental Phobia
Problems with previous Dental Treatment

Does this student require Antibiotics

YesNo
Has this student had dental X-rays in the past 6 months?

YesNo
Please list any allergies
Please list any current medications
Please list any other medical conditions
Do you have any concerns about your childs teeth or oral health
STEP 3
01. 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.adhnsw.com.au/dentaltreatment. I have had an opportunity to ask questions and seek clarification on the information I have been provided by calling ADHNSW on (02) 7803 9608.
- 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 ADHNSW 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 ADHNSW 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 ADHNSW 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.
SIGN HERE

Clear
Date

DayMonthYear
Date
02. 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.
SIGN HERE

Clear
Date

DayMonthYear
Date
03. 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
SIGN HERE

Clear
Date

DayMonthYear
Date
Child Dental Benefits Schedule Bulk Billing Patient Consent Form
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

I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Sched- ule.

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.
*ADHNSW will not charge any out of pocket costs for services completed.
Card Number
Number Next to Name
NAME OF CHILD
Patient/Legal Guardian Signatures
Full Name of Person Signing if not the patient
Date

DayMonthYear
Date
This form is valid up to 31 December of the calendar year for which it is signed.
Private Health Insurance

This section is intended for families with Private Health Insurance. If you do not have coverage, please leave it blank.
Fund Name
Member Number optional
Card Number
Card Issue Date

MonthDayYear
Date
Card Rank
Number next to childs name
Should be Empty:

Paper Form vs. Online Form – Which One Do You Need?

My Child's Medical History & Consent

STEP 3

Child Dental Benefits Schedule Bulk Billing Patient Consent Form

Private Health Insurance