Expert Mobile Dentistry

At Mobile Dentistry NSW, we offer comprehensive dental care services delivered right to your location for a smooth and comfortable experience for every patient in need.

    Initial Visit Consent Form




    Resident's Details


    Does the resident have any dentures?
    Does the resident have any mobility restrictions?
    Are there more than one person appointed as the resident’s Enduring Guardian?


    Medicare Info

    Medicare

    Medicare Card No: *

    Individual Reference No: *

    Medicare Expiry *

    Private Health Insurance (Extras) *

    Provide Insurance Details:

    Medical History

    Please choose if the person has any of the following medical conditions. If you select a condition, please supply further information.

    Other conditions we might need to know about:

    Does the patient have any allergies? *

    If Yes, please provide details:

    Does the patient takes any medicines (prescribed or over the counter) at present? *

    If Yes, please provide details:



    Power of Attorney Details

    Person 1:


    Person 2 (optional):



    Consent

    By signing this form, I give Mobile Dentistry Services permission to attend the dental visit, and to share this consent form and dental report with the aged care facility if requested.

    Contact Us for Mobile Dental Care

    Get Started Today
    Scroll to Top