Dental Planet - FREE Dental Service Enrolment

SECTION 1: ENROL

Please fill out the form below to ENROL your child with Dental Planets on-site dental service
A) Basic Information
Name of Child (Legal)

First NameLast Name
Name of Child (Preferred)

First NameLast Name
Date of Birth (Child)

DayMonthYear
Date
Gender
School your child currently attends
School Year
NHI (if known)
B) Consent
Do you give consent for your child to be seen by Dental Planet for their FREE consultation (including x-rays) at school?
Do you consent for your child to receive treatment for FREE by Dental Planet as necessary?

Other
Additional Comments

C) Medical Information
Please disclose any medical conditions your child may have and any medications they may be taking. Write N/A if not applicable
D) Contact Information
Relationship to Child

Other
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

SuburbPost Code

Post Code

SECTION 2: DECLINE

Please fill out the details below if you wish to DECLINE consent and for DHB reporting purposes.
Name of Child (Legal)

First NameLast Name
Date of Birth (Child)

MonthDayYear
Date
School your child currently attends
Childs current dental practice
Additional Comments

FREE Dental Service Enrolment