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School / Centre Name
Suburb
Child's Name (As shown on medicare card)
Preferred Name
Gender
MaleFemale
Date of Birth
Last Dental Visit
Complete Address
Full Name
Relationship to the Child
Mobile No.
Email
Medicare Card No:
Individual Reference No:
Private Health Insurance (Extras)
YesNo
Private Health Insurance Fund:
Private Health Insurance Membership No:
You will be notified if your child is not eligible for bulk-billing with medicare.
Please tick each box and sign digitally
I consent to check if my child is eligible for the Medicare Child Dental Benefit Scheme If my child is not eligible I agree to payOnce I paid, I would like an invoice to claim on our private health insurance fund.I consent to photos of my child taken by Mobile Dental Health to be used for education purposes and posted on their social media/ website
By signing this form I consent to my child receiving check-up, clean & application of fluoride to the teeth (if necessary). I am aware that I have the option of being present at the appointment and need to contact MDH prior to the date of their visit to book a suitable time.
I am the:
ParentGuardianOther
If other please describe relationship to child:
Parent / Guardian Name:
Date Signed:
Signature (Please type your name as a signature)
I have confidential medical information about my chid that I do not wish to write down. I would prefer to speak to the dental practitioner about this.
Please tick each box that applies and sign digitally.
Does he/she have, or has he/she ever had, any of the following medical conditions?
Rheumatic Fever:
High or Low Blood Pressure:
Heart complaint:
Bronchitis or other lung disease:
Stroke:
Tuberculosis:
Heart Valve Disorder:
Contact with HIV/AIDS virus:
Stomach or digestive condition:
Thyroid Disease:
Growth disorder:
Nervous condition: eg ADD
Cardiac pacemaker:
Epilepsy:
Diabetes:
Prosthetic or other implant:
Radiation therapy:
Kidney disease:
Aenemia,Leukaemia or other blood diseases:
Steroid therapy:
Hepatitis:
Excessive bleeding:
Asthma:
Any other conditions. Please list below:
Extra conditions we might need to know about:
Please complete the following information. If "Yes" please give details
Is your child being treated by a doctor at present?
Treatment details:
Is your child taking any tablets or medicines (prescribed or over the counter) at present?
Medication details:
Does your child usually require anti-biotic cover prior to dental treatment?
Anti-biotic cover details:
Does your child have any abnormal reactions to local or general anaesthesia?
Anaesthetic reactions:
Please list any drugs or medicines your child is allergic to (please enter "none" if nothing known)
Please list any known allergies your child has (including latex). Please enter "none" if nothing known.
Emergency contact name:
Emergency Contact Phone:
Who is your childs usual medical practitioner?
Doctors Phone:
Date:
Patient's Medicare No:
Patient's Full Name
Name of person signing (if not patient)
Parent's /Legal Guardian's Signature
This form is valid up to 31 December of the calendar year for which it is signed
