Childsmile FREE School Dental Program Consent Form

Childsmile™ FREE Dental Program Consent Form
(School)

You can complete and sign this form online in under 3 minutes, no printing needed.
School Name
School Suburb
Year / Grade
Which year is your child in?
Class / Room
Which room/class is your child in?
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
2 digit day, 2 digit month, 4 digit yearEnter manually or use calendar button to select the date of birth.
Gender
Medicare Details
Medicare Card Number
Please enter a valid 10 digit medicare number.
Individual Reference Number (IRN)
Please enter 1 digit IRN Number
Payment
Please select below
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.
Unit/Apt & Street Number
Street Name
Suburb
State
Postcode
ADRESS (HIDDEN)
I understand that The Smiles Dentacare (TSD) will conduct a Medicare Child Dental Benefits Schedule (CDBS) eligibility check for my child prior to the treatment. If my child is eligible, the services listed below will be bulk billed through Medicare at no cost to me, provided my child's CDBS benefit entitlement has not already been used, in full or in part, with another provider during the current benefit period.

Services to be provided:
- Comprehensive dental examination : Full examination of teeth, gums and mouth.
- X-rays (recommended to complete a thorough examination) : Identify cavities, impacted teeth and bone infections.
- Scale, clean and polish : Remove plaque, stain and tartar buildups.
- Fluoride treatment : Strengthens enamel, fights decay
- Fissure sealants (if required) : Shields grooves from cavities
- Other treatments (if required) : TSD will contact parent/guardian to discuss before providing any further treatments
If my child is not eligible for Medicare CDBS, I understand that The Smiles Dentacare will provide a complimentary comprehensive examination, and I will have the option to purchase additional paid services, which is entirely optional.

I understand that I may withdraw this consent at any time before treatment begins, by advising The Smiles Dentacare verbally or in writing.

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.

I also understand that if further treatment is required, The Smiles Dentacare will contact me to obtain my consent before proceeding.
Signature

Use mouse or touchscreen to sign.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearAutomatically selects today's date.
Child's Medical History
Is your child currently receiving any medical treatment?
If 'YES', Please provide medical treatment details below.
Has your child had any serious / long-standing illness?
If 'YES', Please provide serious / long-standing details below.
Does your child currently take any medications?
If 'YES', Please provide medication details below.
Has your child had dental X-rays done in the past 6 months?

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

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.
Please write 'NA' if there are no other conditions.
ALLERGIES (e.g. latex, milk protein, strawberries etc)
Please write 'NA' if there are no allergies.
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 myconsent 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
2 digit day, 2 digit month, 4 digit yearAutomatically selects today's date.
- Patient's Name
  
  First NameMiddle Name (Leave it empty if no middle name)Last Name
- Date of Birth
  
  DayMonthYear
  2 digit day, 2 digit month, 4 digit yearEnter 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
  2 digit day, 2 digit month, 4 digit yearAutomatically selects today's date
Should be Empty:

Childsmile™ FREE Dental Program Consent Form

(School)

Child's Details

Medicare Details

Payment

Parent / Guardian's Details

Child's Medical History