Lilydale High School Dental Consent Form

School Name

Patient Name and Surname

First NameLast Name

Preferred Name

Patient Gender*

Roll Call Class

Mothers Name and Surname

Father Name and Surname

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth

DayMonthYear

Guardian Home Phone

Guardian Work Phone

Guardian Mobile Phone

Guardian E-Mail*

How did you hear about Smiles Onsite?

I would like my child to receive a FREE Dental Examination. I also consent to be contacted if my child needs further treatment.If eligible for the CDBS scheme please provide a scale and clean, polish, removal of deposits and fluoride treatment to the amount of $176.90 and if needed fissure seals ($46.05) and Xrays ($30.45 each) all Bulked Billed through Medicare. (Please check on behalf of my child if they are eligible for the CDBS Scheme).If Not eligible please provide a scale and clean, polish and Fluoride treatment for $99. Please provide your credit card details for payment below.(Payment will be taken once your child has been assessed).

Medicare Number*

Expiry Date*

Next to patient name is the IRN*

Do you have a personal GP?

YesNo

GP Name

Date of Last Visit

GP Phone Number

Is your son/daughter under GP Care?

YesNo

If yes, please explain

Has your son/daughter got any medical condiitons?

If yes, please list

Are you child taking any medication? If yes, please list each one

Do you have any allergies?*

YesNo

If yes, please list

Do you have any disease, condition or problem that you feel we should know about? If so, please describe

Your son/daughter current dental health is

GoodFairPoor

floss/week

brush/day

When was your son/daughter last dental visit?

How can we accommodate your son/daughter better during your dental visit?

Is there any specific service and/or concern you would like to inquire about?

I have read and agree with Medicare CDBS Dental Consent form and Smiles Onsite Privacy Policy.*

First NameLast Name

Medicare CDBS Dental 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 theChild 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 I 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.

Declaration

By submitting this form I have read and agree to Smiles Onsite's Privacy Policy.

Signature*

Date

DayMonthYear

Smiles Onsite Dental Consent Form

Please select the following

Medicare Details

Medical History

Dental History

Terms and Conditions