"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 whether your child is eligible for 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!"

Your Child's School Name: *Please use the school name that you were emailed from.

School Suburb *

Class: *

State: *

Child's Name *

Child's Last Name *

Your Child's Gender *

Child's Date Of Birth *

Medicare Details:

Card Number *If you do not have a Medicare card but would still like your child/ren to participate, Fill in 0000000000

CRN / IRN *Can Be Filled as 1 if you don't have a Medicare Card

Medicare Card Expiry Date: MM/YY *Can be filled as 00/00 if no Medicare Card

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 to your child being 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 / caregiver, certify that I give A & A Smiles consent to the following terms and conditions 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.

*

I understand that eligibility is outside 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 to provide itemised receipts. I understand that I can request reports and receipts from A & A Smiles about the status of my child's oral health condition.

*

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

*

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).

*

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 of baby teeth; and other services covered by the CDBS. All treatment will be carried out only with the full cooperation of the child. No treatment will be completed without the child's willing participation, and nothing will be forced. Treatment will only proceed where it is clinically necessary, and if a child becomes distressed or unwilling, the procedure will be stopped.

*

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 before each service is performed unless deemed necessary by the clinician or patient.

*

I understand that not all treatments can be carried out in the mobile setting, and that actions taken by the clinicians are to prevent further damage or degradation of my child's oral health.

*

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.

I understand that, if my child has an insufficient CDBS balance to cover treatment, I will be advised before any additional costs are incurred.

*

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: *