Child Consent Form

Child's First Name *

Child's Last Name *

Gender *

Date of Birth *

School Name *

Roll Call Class *

Parent/Carer Name *

Parent/Carer Contact Number *

Email Address *

Address *

Subrub *

Postal Code *

Medicare Card Number *

Expiry Date *

Patient's Individual Reference Number *

When did your child last visit a dentist? *

Child’s Dental Habits (ie. Brushing teeth, flossing, grinding) *

Medical Practitioner Name

Medical Practitioner Contact Number

Medical Conditions : ADHD, Asthma, Autism, Heart conditions, Diabetes, Hepatitis A/B/C, Epilepsy, High/low Blood pressure, kidney or liver conditions, other (specify) *

Medications (eg. Ventolin) *

Allergies/ Adverse drug reactions (eg. Penicillin) *

Please tick if applicable: *

Check Child Dental Benefits Scheme (CDBS) eligibility of my child.If not eligible for any benefits under the CDBS.Both

If eligible I consent for my child to receive the following: Comprehensive examination,

Clean (scale or prophylaxis treatment as needed)
Preventative fluoride treatment
Fissure sealants as required (protective measure against tooth decay).

Note: This is Bulk-billed under Medicare (You do not need to pay out of pocket). If you give financial consent, $148.35 may be claimed from your child's CDBS benefits and if required fissure sealants at $46.05 per tooth.

If not eligible under CDBS for any benefits under the CDBS.

I consent for my child to receive the same high quality comprehensive examination, clean (scale or prophylaxis as needed) and preventative fluoride treatment at the discounted rate of $85 (medicare value of $148.35). Payment can be made on the day of treatment via cash, via credit card over the phone or direct deposit into the following details: (BSB: 082-343, Acc: 78-686-3050, Acc name: IMDS, Ref: Child's name). This can be claimed by insurance with no gap depending on cover (if available). Once payment is deducted, a receipt will be emailed to you to provide to your insurance provider.

DECLARATIONS

I have completed the questionnaire to the best of my knowledge
I, the parent/guardian of the above named child have read through and understood the treatments
provided by IMDS and give voluntary consent for IMDS to conduct treatments if deemed appropriate by a registered dental practitioner without myself being present on site but a STAFF member of the facility to be present

I consent for my child to receive the same high-quality comprehensive examination, clean (scale or prophylaxis as needed) and preventative fluoride treatment at the discounted rate of $85 (medicare value of $148.35). Payment can be made on the day of treatment via cash, via credit card over the phone or direct deposit into the following details: (BSB: 082-343, Acc: 78-686-3050, Acc name: IMDS, Ref: Child's name). This can be claimed by insurance (depending on your cover). Once payment is deducted, a receipt will be emailed to you to provide to your insurance provider.

DECLARATIONS

I have completed the questionnaire to the best of my knowledge
I, the parent/guardian of the above named child have read through and understood the treatments
provided by IMDS and give voluntary consent for IMDS to conduct treatments if deemed appropriate by a registered dental practitioner without myself being present on site but a STAFF member of the facility to be present

Date *

Fullname of person signing if not patient

Signature *

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