CONSENT FORM

Please read and complete the following form accurately so that we can see your child!

General Information

Childcare Centre NAME *

Childcare Centre SUBURB *

Patient first name *

Patient surname *

Patient Preferred Name (if different to above)

Patient Gender

Patient Date of birth *

Have we seen your child before?

YesNo

Is the patient of Aboriginal or Torres Strait Islander origin?

YesNo

Email Address *

Mobile phone *

Parent/Guardian Name

Medicare Card Number (including IRN)

Do you have private health insurance?

YesNo

Home Address

Street address

City

Postcode

Emergency contact

Emergency Contact Phone

Medical Practitioner

Medical Practitioner Phone

Medical Consent

It is important for us to know details about your child’s medical history as these could affect the success of your child’s dental treatment. The information you provide is confidential and will be handled in accordance with the Australian Dental Association privacy policy and our Social Media Consent Form. It is important that you fill out the form accurately as this can adversely affect your child’s dental treatment outcomes.

General Questions *

YesNo

Is your child being treated by a doctor at present?

YesNo

Is your child taking any tablets or medications (prescribed or over-the-counter) at present? Please List.

YesNo

Has your child ever been hospitalised?

YesNo

Has your child had any serious or long-standing illnesses?

YesNo

If Yes, please elaborate below.

Details

Please tick any ALLERGIES your child has (if other, please elaborate below). *

Milk proteinLatexOtherNone

Is your child Lactose Free/ Lactose Intolerant? *

YesNo

Other allergies:

Please indicate if you child has ever had any of the following:

Please list any other medical condition/s or oral concerns not listed above that will assist us in providing appropriate oral health care for your child:

I confirm that above information I have provided is true, complete and accurate. *

Signature

Clear

Date

Parent/Guardian Name *

Child Dental Benefits Consent (Bulk Billing) Form

This form is requirement so that we can check your eligibility and to see your child under the bulk billed Child Dental Benefits Scheme. If they are eligible, we will see them on the day. If they are not eligible, we will call you.

The item codes that can be billed for your child and the costs of these codes are available on our website (Child Dental Benefits Page).

Patient's Full Name (as appears on Medicare Card) *

Patient's Medicare Number *

Parent/legal guardian signature *

Clear

Date *

Full name of person signing *

Consent

Mandatory Consent:

I consent to Delivering Dental conducting a CDBS medicare eligibility check for my child. If eligible for CDBS, please provide my child with an oral examination, clean and remineralisation agent application (Tooth Mousse), if possible. I understand that it is the childcare centre’s responsibility to correctly identify my child for the servicing dental practitioner.

If my child is not eligible, I consent to being contacted by SMS/email or phone call to organise prepayment of $75 for the visit (you can cancel at any time).

I consent to Delivering Dental emailing my invoice and child’s dental report following the dental visit. (Please ensure you have filled out your email address clearly on the medical history form).

I also consent to being contacted by SMS or phone call to organise my child's visit.

Please choose one of the following (please note that you will receive a detailed report to your email whether you are present for the appointment or not): *

I would like to attend my child's dental appointment. Please call me to arrange a suitable time.I do not wish to be at the appointment. I would like my child to be seen in a group of their peers with a trusted educator present.

I consent to Delivering Dental taking photos of my child during dental treatment, and to these photos being posted on Delivering Dental Social Media (facebook and instagram @deliveringdental). *

Yes No

Parent/legal guardian signature *

Clear

Date *

Parent/legal guardian name *