Parental Consent Form
Does your child attend school or childcare/kindergarten? * School Childcare / Kindergarten Home visit
Child's Details
Address *
When was your child's last dental examination?
Medicare Info
Medical History
Please choose if your child has any of the following medical conditions. If you select a condition, please supply further information.
ADHD Asthma Heart Conditions Lung Disease Diabetes Kidney Conditions Heart Valve Disorder Infectious Disease/s Artificial Heart Valve Bleeding Disorder Growth Disorder Tuberculosis High/Low Blood Pressure Epilepsy Chronic Conditions Prosthetic or Other Implant Radiation Therapy Steroid Therapy Hepatitis A, B or C Cancer Anemia, Leukemia or Other Blood Diseases
Other conditions we might need to know about:
Does your child have any allergies? * Yes No
If Yes, please provide details:
Is your child taking any medicines (prescribed or over the counter) at present? * Yes No
If Yes, please provide details:
How would you describe the condition of your child’s mouth and teeth? * Excellent Good Poor
Are there any main dental concerns for your child?
Please describe your child's oral hygiene routine:
Consent
Please tick if you agree to the following:
I consent to check if my child is eligible for the Medicare Child Dental Benefit Scheme * Yes No
If eligible, please provide free oral examination / scale / clean / fluoride. If recommended by the Dentist, please also provide fissure seals * Yes No
If not eligible, please select Option 1 or 2 below:
Please note: Our team will contact you to arrange payment prior to the service. If payment is not made prior to the visit, your child will not be seen.
Option 1: Please provide oral examination/scale/clean/fluoride for $99. Parent/guardian will be contacted if additional treatment is required.
Option 2: Please provide oral examination/scale/clean/fluoride/up to 4 x fissure sealants for $179.
I consent to dental radiographs being taken if any concerns are raised by the clinician. * Yes No
I consent to sharing my child's clinical/dental information with other healthcare professionals if necessary. * Yes No
If MDS visits my child’s facility 2 times within the same calendar year I consent to allowing them to see my child for the secondary visit without filling out a new form. * Yes No
I am the * Parent Guardian Other
If other, please describe your relationship to the child:
Parent/Guardian Name *
By signing this form, I certify that I have completed it to the best of my knowledge and give permission for the dental visit. * Yes No
Date Signed *
Signature *
Clear
Bulk Billing Patient Consent Form
Patient/Child's Medicare No: *
Patient/Child's Full Name *
Medicare Expiry *
Name of Person Signing (if not the patient) *
Parent's/Legal Guardian's Signature *
Clear
Date Signed *
This form is valid up to 31 December of the calendar year for which it is signed.
