Consent Form

Child Information

Childcare Centre Name and Suburb *

Childcare Centre address *

Child First Name *

Child Last Name *

Gender *

MaleFemale

Date of Birth *

Home Address *

Parent/Guardian Full Name *

Parent/Guardian Email Address *

Parent/Guardian Phone Number *

Is your child of Aboriginal or Torres Strait Islander origin?

YesNo

Emergency Contact *

Emergency Contact Phone *

Medical Practitioner *

Medical Practitioner Phone *

Child's Medical History

Does your child have any medical conditions that we should be aware of? *

Yes No

If yes, please provide details

Has your child has any surgeries or been hospitalised in the past? *

Yes No

If yes, please provide details of past surgeries or hospitalisations

Is your child being treated by a doctor at present? *

Yes No

If yes, please provide details of the treatment

Has your child had any serious or long-standing illness? *

Yes No

Details for serious or long standing illness

Does your child have any allergies such as latex, milk protein, peanuts, or other? *

Yes No

Details of allergies

Please list any oral concerns? *

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

Consent

I consent to Dental for Tiny Teeth conducting a check up, clean and remineralisation treatment at the childcare centre. The childcare centre will correctly identify my child for the oral health practitioner. I have disclosed all relevant information about my child. I understand that I will receive a dental report and receipt after the visit has been completed.

I will be attending my child's appointment *

Yes No

I consent to photos and videos being taken during education and dental treatment and being published on the website, social media and used in promotions *

YesNo

Consent Parent/Guardian Signature *

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Date of Consent *

Payment Options

Dental for Tiny Teeth provides a dental comprehensive exam, clean as well as remineralisation. Your options for payment are:

1. Fully covered by the Child Dental Benefit Scheme (CDBS). Your child's eligibility is dependent on if you are receiving certain payments from Centrelink.

The item numbers are 88011 ($55.40) or 88012 ($47.90 - depending on eligibility), 88111 ($56.60) and 88121 ($36.35).

You can check your eligibility here: https://www.servicesaustralia.gov.au/eligible-payments-for-child-dental-benefits-schedule?context=22426

THIS IS SUBJECT TO ELIGIBILITY CHECK. IF YOUR CHILD'S PAYMENT GETS REJECTED ON THE DAY OF SERVICE THEN YOU WILL BE ASKED TO PAY $70.

2. $70 Private Health Fund - this needs to be paid prior. An itemised receipt will be provided for you to claim after the appointment. If you would like to check your coverage the item numbers are 011 ($35), 111 ($25) , 121 ($10).

Please select private payment.

3. $70 for Private paying children- this needs to be paid prior to appointment. Please select private payment.

Payment Option

Payment *

Child Dental Benefit Scheme (ONLY FAMILIES RECEIVING PAYMENTS FROM CENTRELINK)Private Health Fund/Private Payment

Payment must be paid prior to appointment.

Child Dental Benefit Scheme (Only for families receiving payments through Centrelink)

The following form is requirement so that we can confirm your child's eligibility under CDBS.

Medicare Card Number *

Medicare Child Individual Reference Number *

Medicare Date Expiry *

When was your child's last dental check up and clean ? *

I understand that CDBS eligibility checks are completed prior to day of service. I am happy to pay $70 if the CDBS is rejected on day of service. *Please write Yes

Parent/Guardian Signature *

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Date *

Make Your Payment

Private Payment $70.00 + 2.13% surcharge ($71.49) *

Pay

You will receive a copy of your completed consent form by email.

Thank you for your participation in this program.

A healthy mouth is a healthy life .