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Child's Full Name
Date Of Birth
Gender FemaleMaleNot represented herePrefer not to say
Child's School Name
Child's Year / Class
Child's Year / Class Previous Dental Experience Never seen a dental professional beforeLess than 6 months ago1-2 years ago2 or more years ago
Medicare Number
Reference Number
Expiry Date
Prefix MrMrsMissDr
Your Full Name
Address
Suburb
State
Postcode
Email
Contact Number
Secondary Contact Number
Relationship to Child
Does your child have any medical conditions? If yes, please list all.
Does your child have any allergies? If yes, please list all.
Is your child taking any medications? Please list all.
Do you have any dental concerns or comments to add?
We will provide a full comprehensive dental examinations both intra and extra-oral, dental health screening, customised tooth brushing and dietary advice, scale and polish and fluoride treatment and xrays if necessary.
If your child is eligible for the Medicare Child Dental Benefit Scheme, we will cover the cost of this visit bulk billed through Medicare, at no additional cost to you. Codes we may claim will be an 88011 (exam), 88111 or 88114 (polish or scale and polish), 88121 (fluoride treatment) and/or 88022 (xrays).
If your child is not eligible for the Medicare Child Dental Benefit Scheme, Mobile Dental Health is happy to offer a significant discount compared to local pricing to your child. We will be in contact if your child is not eligible for the Medicare scheme (CDBS) to organise payment. We will make contact with you if there will be an out of pocket expense for our visit.
Have you received confirmation your child is eligible for the Medicare Child Dental Benefit Scheme? (Please note: not all children are eligible for this scheme). Leave unchecked if no or unsure.I understand if my child is eligible for the Medicare Child Dental Benefit Scheme, Mobile Dental Health will Bulk Bill for treatment provided, and if NOT eligible OR the limit has been reached on the Child Dental Benifit Scheme, I will be personally responsible for the out of pocket expenses of the treatment provided for my child.
By submitting below you are consenting to Mobile Dental Health providing any of the necessary preventive treatment which may include a dental examination, scale, polish, X-rays and/flouride at the appointment.
