Tooth Fairy

Tooth Fairy

SCHOOL STUDENT CONSENT
STUDENT INFORMATION:
Name

Childs First NameChilds Last Name
Date Of Birth

MonthDayYear
Date
Gender
School Name
Year Level
PARENT/GUARDIAN INFORMATION:
Name

First NameLast Name
Contact Number
Email
example@example.com
Address
Street Address
City
State
Country
Postal Code
Is your child of Aboriginal or Torres Strait Islander origin?

YesNo
MEDICAL HISTORY:
Please indicate if your child has any of the following conditions:

AsthmaADHDAutism Spectrum DisorderDiabetesEpilepsyHeart conditionsBleeding disordersKidney diseaseInfectious conditionsArtificial heart valveTuberculosisHepatitis (A, B, or C)High or low blood pressureNone of the aboveOther (please specify in next section)
Other (medical conditions, please specify):
Does your child have any known allergies? Please list the Allergies:

YesNo
Please list the Allergies
Is your child currently taking any medications?

YesNoIf Yes, please list:
ORAL HYGIENE & HABITS:
How would you rate your child's current oral health?

ExcellentVery GoodGoodFairPoor
How often does your child consume sugary foods/drinks?

Less than once daily1-2 times per dayWith mealsBetween meals
Primary water source for drinking:

TapBottledTank/WellOther water source
Tooth brushing frequency:

Less than once dailyOnce dailyTwice dailyThree or more times
Use of fluoride toothpaste:

AlwaysSometimesRarely/Never
Use of fluoride toothpaste:

AlwaysSometimesRarely/Never
Brushing before bedtime:

AlwaysOftenOccasionallyRarely/Never
MEDIA CONSENT FOR AWARENESS AND EDUCATION
I give permission for photos or videos of my child to be used by Tooth Fairy for marketing, educational, and oral health awareness purposes.

YesNo
DENTAL TREATMENT CONSENT
I authorise Tooth Fairy to provide the following dental services, if deemed necessary by the treating dentist.

YesNo
What is a fissure sealant? Fissure sealants are a plastic coating applied to children's back teeth and are a safe and painless way of protecting your children's back teeth from tooth decay. Most tooth decay in children occurs in their back teeth.

How are fissure sealants applied? It is quick and straight forward, taking only a few minutes per tooth. Our Dentist will clean and prepare the tooth with a special solution. The tooth is dried with air. The liquid is then applied and set hard using a special light. It is pain free.

How long do they last? They can last for many years and the dentist may check them at each check up. They can wear over time and your Dentist may add or replace some sealant

Can my child still be seen if they are not eligible for the free dental service? YES! Our Dentist can see your child and provide them with an oral examination, clean and fluoride for just $XX. We will provide you with a receipt and you can claim on your private health insurance if applicable. If not eligible, and recommended by the dentist, please provide clean / polish / fluoride for $90. This can be reimbursed by your private health insurance provider.
Can my child still be seen if they are not eligible for the free dental service? YES! Our Dentist can see your child and provide them with an oral examination, clean and fluoride for just $XX. We will provide you with a receipt and you can claim on your private health insurance if applicable

If not eligible, and recommended by the dentist, please provide clean / polish / fluoride for $90. This can be reimbursed by your private health insurance provider.If not eligible, and recommended by the dentist, please provide clean / polish / fluoride / 4 x protective fissure sealants for $190. This can be reimbursed by your private health insurance provider
Is your child receiving treatment from another dentist?

YesNo
Have you been to dentist in last six months? Date

MonthDayYear
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 understand / 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 I will need to personally meet the costs of any additional services once benefits are exhausted.
Patients Medicare number
Patient/legal guardian signature
Patient's full name
Full name of person signing
Date

MonthDayYear
Date
Patient legal guardian signature

Clear
Medicare Card Number:
Individual Reference Number IRN on the Medicare card
Single digit number given against the left side of your name
Expire Date

MonthDayYear
Date
This form is valid up to 31 December of the calendar year for which it is signed
INFORMATION FOR PARENTS - SCHOOL
What services is offered?

Tooth Fairy Express is a unique initiative that provides high quality, on-site dental care to children aged 2-17. Under the Child Dental Benefits Schedule (CDBS), funded by Medicare / Australian Federal Government, our service for eligible* children come at no cost to the school or the parents.

Who are the Dentists?

Tooth Fairy Express comprises a team of accredited and experienced Dentists and Oral Health Therapists with a keen desire to provide early intervention and essential dental care to children.

After receiving written consent from you as their parent/guardian, your child will be provided with:

> Cleaning of teeth and fluoride application. Fissure seals and temporary fillings for eligible children if recommended by

> A letter will be provided on the day of your child's visit outlining the treatment they received and/or if further treatment is required Additional Care: > We will contact you if the Dentist recommends an extraction.

What does it cost?

Eligible Children*: For eligible children, the total benefit under Medicare (CDBS) is capped at $1000 over a two-calendar year period. We confirm eligibility with Medicare prior to your child's consultation with our Dentist. Eligibility for this service is linked to recipients of Family Tax Benefit A.

Ineligible Children: For children not covered under Medicare (CDBS) we can provide Preventative Care for $99.00 per child. This includes oral examination, teeth clean and fluoride application, plus a letter setting out your child's current oral health status. Payment is available via EFT / Credit Card / PayPal for your convenience. HEALTH FUND RECEIPTS WILL

How can my child participate in the program?

Your child can participate in the program after filling in our consent form/medical questionnaire. This form needs to be re-turned to school prior to your child seeing the Dentist.

Where can I go for more information on this scheme?

To learn about the CDBS, head to the Medicare website at: www.humanservices.gov.au/healthprofessionals/services/child-dental-benefits-schedule,/
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Tooth Fairy

STUDENT INFORMATION:

PARENT/GUARDIAN INFORMATION:

MEDICAL HISTORY:

ORAL HYGIENE & HABITS:

MEDIA CONSENT FOR AWARENESS AND EDUCATION

DENTAL TREATMENT CONSENT

INFORMATION FOR PARENTS - SCHOOL