St John's Regional College 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 give consent to a free dental examination by Smiles Onsite (if xrays are required it will be bulked billed through Medicare)I give consent to a dental assessment, scale and clean, polish & fluoride treatment carried out by Smiles Onsite (Bulked Billed; NO GAP payable; to the value of $176.90 if eligible through Medicare Child Dental Benefits Schedule (CDBS) and if required fissure seals ($46.05 each) and X-rays ($30.45 each)If Not eligible please provide a scale and clean, polish and Fluoride treatment for $99. X-rays ($15 each) and Fissure Seals ($28 each). Payment will be taken over the phone once your child has been examined.I would like to be present at all the appointments if possible.I do not want to participate in the program

Medicare Number*

Expiry Date*

Next to patient name is the IRN*

Name as printed on Card

First NameLast Name

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

Payment of $99 for Scale and Clean Package

Medical History

Dental History

Terms and Conditions