Dental Consent eForm

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Dental Consent eForm

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Childs First Name*
Childs Last Name*
Gender*
- Male
- Female
- Other
Childs Date of Birth*
Date Format: MM slash DD slash YYYY
Class / Grade*
Does your child attend School or Childcare / Kindergarten?*
- School
- Childcare / Kindergarten
School Name*
Childcare / Kindergarten Name*
Location / Suburb

Room / Group
Individual Reference Number*
Single number next to patient name
Do you have a Medicare card?
- Yes
- No
Medicare Number*
10 Digit Number
What is the Child Dental Benefits Schedule (CDBS)?

With assistance from the Federal Government, Medicare has introduced a Child Dental Benefits Schedule (CDBS) that provides children access to basic dental services from the ages of 2-17 years old. The entitlement is capped at $1,000 per child for every two calendar year period.

Am I eligible for CDBS and how do I claim?

To be eligible, you or the child must be claiming one of the following benefits: Family Tax Benefits-Part A, Parenting Payment, Abstudy, Youth Allowance, Carer’s Payment, Disability Support Pension, Special Benefits or Double Orphan Pension. To enquire if your child is eligable, please contact Medicare on 132 011. Once your child’s forms have been completed, we will individually check each child’s eligibility to see if treatment can be bulk billed through Medicare.

If my child is not eligible for the CDBS, how much does it cost?

If your child is not eligible for the CDBS funding, Mobile Healthcare can offer a verity of services.
To claim NO GAP services under your health fund please present and swipe your Private Health Fund Card to the mobile clinic at the time of appointment for on-the-spot claiming.
*
- IF NOT ELIGIBLE under CDBS, please provide oral hygiene instructions, a full oral examination, scale and clean of debris and deposits and fluoride application for $50 – Refer to the last page for payment options
- IF NOT ELIGIBLE under CDBS, please provide oral hygiene instructions, a full oral examination, scale and clean of debris and deposits, fissure sealants (a pain free coating applied to back teeth to prevent tooth decay) on all 4 of my child’s back molar teeth and fluoride application for $100 – Refer to the last page
- IF NOT ELIGIBLE, please only provide FREE oral hygiene instructions and a full oral examination
- IF ELIGIBLE under Medicare's Child Dental Benefits Schedule (CBDS), please provide oral hygiene instructions, a full oral examination, scale and clean of debris and deposits, fissurs sealants (a pain free coating applied to back teeth to prevent tooth decay) and fluoride application - Please complete the next page.
Parent, Guardian or Emergency Contact Details

Parents/Guardian Last Name*
Parent/Guardian First Name*
Relationship to Patient*
Parent or Guardian Phone Number*
- Landline
- Mobile
Parent or Guardian Landline*
Parent or Guardian Mobile*
Alternative Contact Number
- Landline
- Mobile
Alternative Contact Landline
Alternative Contact Mobile
Street Address*
Suburb / City*
State*
Postcode*
Email*
Known Medical Conditions
- ADHD
- Artificial Heart Valve
- Asthma
- Autism
- Bleeding Disorder
- Chronic Conditions
- Diabetes
- Epilepsy
- Hepatitis A, B or C
- Heart Conditions
- High/Low Blood Pressure
- Infectious Disease/s
- Kidney Conditions
- Tuberculosis
- Other

Further Information
Medical History
Please choose if your child had/has any of the following medical conditions. If you select a condition, please supply any further information.
Does your child have any allergies?*
- Yes
- No
Please provide additional information below*
Is your child currently taking any medications?*
- Yes
- No
Please provide additional information below, including if an Epipen is required?*
Does your child have any conditions or disabilities that may affect their treatment, (example wheelchair access)?*
- Yes
- No
Has your child had any operations?*
- Yes
- No
Please provide additional information below*
Please list the Medical Operation(s) and date*
Are there any main dental concerns for your child?*
- Yes
- No
Please provide additional information*
Social Media / Marketing Consent

In accordance with the Australian Privacy Principals, Part 2 - Collection Of Personal Information.
I hereby give consent for the use of my child’s photo / video material to be utilised by the company for the marketing/social media.
- Yes
- No

Medicare Card Number*
Patient's name*
First Last
CHILD DENTAL BENEFITS SCHEDULE
BULK BILLING PATIENT 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 the child 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 avalibale under the benefits caps.
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 service may have restrictions and that child Dental Benefits Schedule cobers a limited range of services. I understandI 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.
Patient (if over 18) or Parent / Guardian's Signature*
Name of Person Signing*
First Last
Date*
Date Format: MM slash DD slash YYYY

Patient Consent
By signing this form I, the patient/legal guardian certify that: I have completed the form to the best of my knowledge; I understand that failure to make a full disclosure may place my child at undue medical risk or compromise their treatment; I give my child permission to leave the facility to attend the mobile health care with a member of staff; I understand that by completing this form, I give Mobile Healthcare permission to see my child for 2 visits in this calendar year ;
Declaration*
- Yes, I have read and understand the information listed above
Parent/Guardian Signature*
Date Signed
Date Format: DD slash MM slash YYYY
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Contact Detail

Suite 221/ 10-12 Flushcombe Rd
Blacktown,
NSW
2148

Tel: 1300 291 199
admin@themobilehealthcare.com.au

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Dental Consent eForm

Step 1 of 7

What is the Child Dental Benefits Schedule (CDBS)?

Am I eligible for CDBS and how do I claim?

If my child is not eligible for the CDBS, how much does it cost?

To claim NO GAP services under your health fund please present and swipe your Private Health Fund Card to the mobile clinic at the time of appointment for on-the-spot claiming.

Parent, Guardian or Emergency Contact Details

Medical History

Social Media / Marketing Consent

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM

Patient Consent

CHILD DENTAL BENEFITS SCHEDULE
BULK BILLING PATIENT CONSENT FORM