Smile Heros Consent Form

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Smile Heros provides free dental education and preventative care to eligible children under the Child Dental Benefits Schedule (CDBS). Children not eligible can still receive care at a reduced rate.

I agree and understood

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About the Program
The CDBS offers up to $1,132 in dental benefits over two years for eligible children. Eligibility is based on receiving government payments such as Family Tax Benefit Part A.

You can check your child’s eligibility on myGov or by calling Medicare at 132 011. Our team will also verify eligibility on your behalf.

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For Children Not Eligible for CDBS and Without Private Health Insurance
A discounted $90 fee applies for:

Dental exam
Cleaning
Fluoride treatment

A further $95 covers up to 4 fissure sealants, if required.

Payment can be made on the day via bank transfer:

BSB: 062 428
Account: 10498092
Name: Joumana Doumat
Ref: Child’s name

Please note: If a child has private health insurance, we will claim the full amount through their health fund and will only request payment if there is a gap, depending on the level of cover.

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What to Expect
Our friendly team uses portable dental equipment onsite. Services include:

Detailed dental exam
Cleaning
Fluoride application
Sealants (if needed, with consent)

A report will be emailed to parents 3-5 business days after the visit.

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Child's Name* This field is required.

First Name

Last Name

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Gender* This field is required.

Male

Female

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Date of Birth* This field is required.

Date

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School Name* This field is required.

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School Address* This field is required.

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Parent/Carer Name* This field is required.

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Parent/carer contact number* This field is required.

Please enter a valid phone number.

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Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Parent's/Carer's Email* This field is required.

example@example.com

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Roll Call Class* This field is required.

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When did your child last visit a dentist?* This field is required.

Date

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Child's Dental Habits (ie. Brushing teeth, flossing, grinding)* This field is required.

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Medical Practitioner* This field is required.

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Medical Conditions: ADHD, Asthma, Autism, Heart Conditions, Diabetes, Hepatitis A/B/C, Epilepsy, High/Low Blood pressure, kidney or liver conditions, other (specify)* This field is required.

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Medications (eg. Ventolin)* This field is required.

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Allergies/Adverse drug reactions (eg. Penicillin)* This field is required.

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1. Medicare Number (10 digits)* This field is required.

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2. Patient's Individual Reference Number* This field is required.

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3. Expiry Date* This field is required.

Date

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Private health insurance provider (for dental): (BUPA, NIB, AHM, CBHS, HBF, HIF etc)* This field is required.

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Membership/Customer #(Also called Member #, Customer #, or Membership #)* This field is required.

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Patient #/ Card Rank ? Dependent #: usually listed next to the child’s name * This field is required.

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Card Issue # (if listed) This may be called Card Issue # — leave blank if not applicable

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Please tick the box, if applicable:* This field is required.

I authorize Smile Heros to verify my child’s CDBS eligibility.

I authorize Smile Heros to claim via Medicare

I authorize Smile Heros to claim via the private insurance on my child’s behalf.

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Consent for Treatment (tick if you consent)* This field is required.

I agree to the following : Detailed dental exam, Cleaning (scaling or polish), Fluoride treatment and Fissure sealants (if necessary)

If my child is not CDBS eligible, I agree to pay $90 for preventative treatment and an optional $95 for sealants.

My child has private health insurance. I authorize My Smile Heros to submit a claim on our behalf for the full treatment cost, and I agree to pay any gap amount based on our level of cover.BackNext

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Please tick the box: I have completed the questionnaire to the best of my knowledge. I, the parent/guardian of the above named child, have read through and understood the treatments provided by IMDS and give voluntary consent for IMDS to conduct treatments if deemed appropriate by a registered dental practitioner without myself being present on site but a STAFF member of the facility to be present - Note: We may disclose your child's health information to other (health care) professionals, or require it from them if, in our judgement, it is necessary in the context of his/her treatment.* This field is required.

Agree

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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 up to the benefit cap. I understand that benefits for some services may have restrictions and that the 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.

Declarations:

1. I have completed the questionnaire to the best of my knowledge
2. I, the parent/guardian of the above named child have read through and understood the treatments provided by MIDS and give voluntary consent for IMDS to conduct these treatments if deemed appropriate by a registered dental practitioner without myself being present on site but a STAFF member of the facility to be present -

Note: We may disclose your child’s health information to other (health care) professionals, or require it from them if, in our judgement, it is necessary in the context of his/her treatment.

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Please confirm understanding* This field is required.

Agree

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Patient's Medicare number:* This field is required.

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Patient's name:* This field is required.

First Name

Last Name

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Full Name of Person signing (if not patient):Your answer* This field is required.

First Name

Last Name

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Date* This field is required.

Date