A & A Smiles Consent Form

"Thank you for choosing A & A Smiles for your child’s dental care. We kindly ask that you fill out every section of the consent form to the best of your ability. This information is crucial for us to identify any major health concerns for your child and helps us determine if your child is eligible for the treatment under the CDBS. We will contact you if your child is ineligible. Your cooperation ensures that we can provide the best possible care for your child. Thank you!"

The School that emailed you about our service *Please use the school name that you were emailed from.

Name of School if not listed

School Suburb *

Class

State: *

Child's Name *

Child's Last Name *

Your Child's Gender *

Child's Date Of Birth *

Card Number *

CRN / IRN *

MM/YY *Medicare Card Expiry Date:

Guardian Name: *

Guardian Last Name: *

Guardian Phone: *

Guardian Email Address *

Address

Street address

City

State

Postcode

Please provide all relevant medical conditions/ past surgeries /allergies or medications that your child may have, or is taking. *

Do you have any specific concerns about your child’s teeth?

Do you Consent for your child to be photographed without any identifying features showing. Images may be posted on our social media page. *

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM

I, the patient /parent / legal guardian/ care giver, certify that I give A & A Smiles consent to the following terms and conditioins for treatment:

I give consent for my child to participate in the upcoming dental education and check-up session being carried out by A & A Smiles at my child’s school. I confirm and understand that without consent my child cannot be checked or treated on this day.

*

If your child is ineligible, you will be contacted directly via sms, email and or phone call from A & A Smiles in advance.

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I understand that eligibility is out of A & A Smiles' control and is dependent on individual circumstances. A & A Smiles will strive to be transparent and open about all treatment carried out and provide itemised receipts. I unnderstand that i can request reports and receipts from A & A Smiles about the status of my childs oral health condition.

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I agree for A & A Smiles to seek eligibility from Medicare® Australia for my child/ren and give consent for A & A Smiles to bulk bill Medicare® Australia for treatments carried out on that day.

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That I provide consent for my child to receive all sound dental treatment deemed clinically necessary by the attending dental practitioner, under the Child Dental Benefits Schedule (CDBS).

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I consent for A & A Smiles to carry out any treatment deemed clinically necessary which may include (but is not limited to) examinations of the head, neck and oral cavity, X-rays (as deemed necessary), preventative care (such as fissure sealants and fluoride), fillings/ restorations using tooth coloured (composite resin) materials, non surgical extractions and other services covered by the CDBS.

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That I understand and agree that the treating clinician will exercise their highest professional judgement in determining the treatment required, and I will not be contacted prior to each service being performed unless deemed necessary by the clinician or patient.

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I understand that not all treatments can be carried out under the mobile setting that actions taken by the clinicians is to prevent further damage or degradation of my childs oral health.

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That I have been informed that I will be advised of the costs of treatment by the clinician following completion of the treatment, and that all eligible treatment will be bulk billed directly to Medicare, with no out-of-pocket costs to me, provided sufficient CDBS funds remain under the benefit cap.

That I understand if my child has insufficient CDBS balance to cover treatment, I will be advised prior to any additional costs being incurred.

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That I have been made aware of my right to ask questions about treatment and consent before signing this form.

*

Signature *

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Guardian's Name: *

Date: *