Dental Outreach Program Consent Form

Dental Outreach Program Consent Form
(CHILDREN)

You can complete and sign this form online in under 5 minutes, no printing needed.
Facility/Venue Name
Facility/Venue Suburb
Child's Details

Please enter child's name exactly as shown on the medicare card
Child's Name

First NameMiddle Name (Leave it empty if no middle name)Last Name
Preferred Name
Date of Birth

DayMonthYear
Enter manually or use calendar button to select the date of birth.
Gender
Medicare Details
Medicare Card Number
Please enter 10 digit medicare number.
Individual Reference Number (IRN)
Please enter 1 digit IRN Number
Payment Options
Please select one
Parent / Guardian's Details
Parent/Guardian's Name

First NameLast Name
Email
Enter a valid email address to receive dental reports.
Mobile Number
Enter a valid mobile number to receive program reminders and other notifications.Format: 0000 000 000.
Street/Unit/ Apartment Number
Street Name
Suburb
State
Postcode
I understand that The Smiles Dentacare will conduct a Medicare CDBS eligibility check for my child prior to treatment. If my child is eligible, all services will be bulk billed at no cost to me.

Services to be provided:
- Comprehensive dental examination
- Scale, clean and polish
- Fluoride treatment
- Fissure sealants (if required)
If my child is NOT eligible, I understand that The Smiles Dentacare will provide a complimentary comprehensive examination and report at no cost. I will then have the option to purchase additional services, which is completely optional. I understand that The Smiles Dentacare may contact me via email or text message to inform me about these additional optional paid services.

By signing below, I confirm that I am the parent or legal guardian of the child named above, that I have read and understood the above, and that I consent to The Smiles Dentacare conducting a Medicare eligibility check and providing the services listed.
Signature

Use mouse or touchscreen to sign.
Date

DayMonthYear
Automatically selects today's date.
Child's Medical History
Is your child currently receiving any medical treatment?
If 'YES', Please provide details below.
Has your child had any serious / long-standing illness?
If 'YES', Please provide details below.
Has your child ever been hospitalised?
If 'YES', Please provide details below.

Please indicate if your child has ever had any of the following? Please tick YES or NO.

Rows	YES	NO
Any heart complaint/treatment
Rheumatic fever
High/low blood pressure
Any nervous system disorder
Kidney conditions
Tuberculosis
Chronic conditions
Epilepsy
Asthma/bronchitis/lung conditions
Blood disorders/bleeding disorders
Infectious disease (measles/chickenpox etc)
Hepatitis A,B or C
Diabetes
Other

Other conditions (e.g. ADHD, Autism), oral concerns not previously mentioned that may assist us in providing appropriate oral health care for your child.
ALLERGIES (e.g. latex, milk protein, strawberries etc)
I confirm that I am the parent or legal guardian of the child named above and have the authority to provide consent on their behalf. I acknowledge that I have been informed of the approximate cost of treatments to be claimed through the Medicare Child Dental Benefits Schedule (CDBS). I hereby give informed consent for The Smiles Dentacare (TSD) to collect, use, and disclose relevant information as necessary to provide dental care and treatment. I understand the nature of the treatment and that I may ask questions or withdraw my consent at any time.
I confirm that the information provided is true and accurate to the best of my knowledge. I understand that this form is a guide only and that I should discuss any relevant matters with my dental practitioner prior to commencement of treatment.
Signature

Use mouse or touchscreen to sign.
Date

DayMonthYear
Automatically selects today's date.
Patient's Name

First NameMiddle Name (Leave it empty if no middle name)Last Name
Date of Birth

DayMonthYear
Enter manually or use calendar button to select the date of birth.
Medicare Card Number
Please enter 10 digit medicare number.
Individual Reference Number (IRN)
Please enter 1 digit IRN Number
Form completed by
Full name of the person completing this form

First NameLast Name
Signature

Use mouse or touchscreen to sign.
Date

DayMonthYear
Automatically selects today's date
Should be Empty:

Dental Outreach Program Consent Form

(CHILDREN)

Child's Details

Medicare Details

Payment Options

Parent / Guardian's Details

Child's Medical History