Dental Planet - FREE Dental Service Enrolment

FREE Dental Service Enrolment
Do you wish to ENROL your child or DECLINE our service?*

Enrol (complete section 1)Decline (complete section 2)

SECTION 1: ENROL

Please fill out the form below to ENROL your child with the Tooth Group - onsite 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 The Tooth Group for their FREE consultation (including x-rays) at school?*

YesNo
Do you consent for your child to receive treatment for FREE by the Tooth Group as necessary?*

YesNoOther
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*

ParentGrandparentLegal GuardianSelfOther
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 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